UMSL - UNIVERSITY OF MISSOURI-ST. LOUIS
Disability Access Services
Division of Student Affairs
REQUEST FOR SPECIAL SERVICES
STUDENT INFORMATION FORM
Program Application
I. GENERAL FORM
1. Name ______________________________________________ Date ________________
2. Current Local
Address:__________________________________________________________________
(Street, Apt #)
_________________________________________________________________________
(City, State, & Zip Code)
3. Phone:________________________________ _________________________________
(Home #) (Cell #)
_________________________________________________________________________
UMSL Email address: Off Campus Email Address
4. Birth Date #:_______________ Student I.D.#___________________
II. ADMISSION INFORMATION : Please check the semester that you are applying for services:
5. Semester for which you are applying:
Fall Winter/Spring Intercession
Other
Summer
6. Your Current Academic Classification: (Check one)
Entering Freshman Visiting Student Transfer Freshman
Sophomore Junior Senior
Unclassified
Graduate
7. Declared Major: ___________________________________________________
III. DISABILITY CATEGORIES:
8. Disability: (Check all that apply)
deaf/hard of hearing
blind/low vision
specific learning disorder
attention deficit disorder
mental health
orthopedic
speech/language
traumatic brain injury
Other _____________________________________________________________

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9. What is the medical diagnosis of your disability? __________________________________
____________________________________________________________________________
10. Age of onset of disability: ___________
11. What is the prognosis of your condition? Stable
degenerative likely to improve unknown
12. What problems or inconveniences, if any, does your disabling condition cause in class?
_________________________________________________________________________
_________________________________________________________________________
13. How do you solve the problems?
_________________________________________________________________________
_________________________________________________________________________
14. What special equipment (if any) do you use in everyday living?
________________________
15. Do you have any other disability or impairment (for example: perceptual difficulty; seizure disorder; respiratory ailments; chemical dependence; mental, emotional; etc.)
Yes no If yes, please explains:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
no 16. Is supporting documentation of your disability available? Yes
If yes, please attach. If no, please supply as soon as possible.
IV. EDUCATIONAL INFORMATION
17. High School: IEP Mainstreamed
Name of School
_________________________________________________________________________
Post Secondary: Received accommodations yes no
Name of School____________________________________________________________
18. Name of most recent Disability Student Services Coordinator.
_________________________________________________________________________
Name School/Institution
May we contact the individual named above to discuss your previous accommodations while attending that institution? □ yes □ no
If yes, please sign below authorizing permission to speak with the individual named above or other institutional representative.
_________________________________________
Signature
________________
Date

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V. SUPPORT SERVICES/CLASSROOM ACCOMMODATIONS
Previous:
accessible classrooms
braille materials
alternate textbook format
testing accommodations
taped lecture
other (please describe below)
Please describe other services you think you may need:
_____________________________________________________________________________
_____________________________________________________________________________
VI. FINANCIAL ASSISTANCE
22. Have you applied for financial aids?
23. Have you applied to Vocational Rehabilitation? yes
yes no
no If yes,
Name of Counselor: _______________________________________________________
Address: _______________________________________________________________
May we contact the individual or office checked above if necessary to coordinate funding for your accommodations? yes no
If yes, please sign below authorizing permission to speak with your Voc Rehab or other named agency representative.
__________________________________
Signature
__________________________
Date
19. Have you had support for your disabling condition before? yes no
20. If yes, explain what (tutors, notetakers, etc.) and where (high school, grade school, etc.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
21. Accommodations and/or Auxiliary Aids Requesting at UM-St. Louis:
Check the services you think you may need:
interpreter notetaker
reader
extended test time
lab assistant
alternative test location
writer
enlarging equipment
large print materials
computer access

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24. To help us if we need to work with appropriate agencies or advise you about financial procedures, please check if you are receiving assistance from:
Division of Vocational Rehabilitation
Veterans Administration
Employer
Financial Aid
Other (specify) _____________________________________________________
May we contact the individual or office checked above if necessary to coordinate funding for your accommodations? yes no
If yes, please sign below authorizing permission to speak with your Voc Rehab or other named agency representative.
__________________________________ __________________________
Signature Date
The information contained and submitted in this form will remain confidentially on file in Disability
Access Services. Your private responses will only be used in the assessment of your classroom accommodations .
As a service to students with disabilities registered with DAS, this office will print and provide you with disability notification memos for your courses. This service benefits you as a student by, notifying instructors that you may need classroom accommodations or adjustments. The memo also verifies your eligibility to request classroom accommodations.
Your official disability notification memos will be prepared each semester that you register with
DAS. The notification memos will be available for students the week prior to the start of classes.
You will be responsible for personally picking up and hand delivering your notification memos to your instructors each semester .
Do you want to utilize this service for the current semester? □ Yes □ No
________________________________________ _________________________
Student’s Signature Date
Revised 2/9/12