Student Accessibility Services Inquiry Form

* = required field

Name *

First

Last

Address *

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number *

###

####

Email Address *

Date of Birth

YYYY

Year in School *

Major *

Academic Adviser/Academic Counselor *

Person You were Referred by

First

Last

Reason You were Referred

Do You have Documented Disability? *

Yes

If yes, please describe below

Do You have a Chronic Medical Condition? *

Yes

If yes, please describe below

Do You have Mental Health Condition? *

Yes

If yes, please describe below

Accommodation You have Received in the Past

Release of Information

I authorize that Angela Moureau, from the Milwaukee School of Engineering, may obtain my academic and/or medical records in order to prepare my accommodation plan for this school year.

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Student Accessibility Services Inquiry Form

Release of Information

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