Application for Disability Services

Please be sure to read the following before completing this application:
Application Instructions & Guidelines for Documentation of a Learning Disability
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 Student ID (Social Security No.)  On Campus Extension  Classification

 First Name  Middle Initial  Last Name

 Age  Date of Birth  Gender
Male     Female

 Local Address  City  State  Zip

 Local Phone No.
 May We Leave A Message?
  E-mail Address
 May We Send A Message?
Yes     No
Yes     No

 Permanent Address  City  State  Zip

 Permanent Phone
 May We Leave A Message?
  Date of Initial Enrollment at McMurry
Major
Yes     No

 List Disability(s)
  Date of Onset/Initial Diagnosis

 List limitations disability has on student's
 functioning at McMurry
  Name of Texas Rehab Commission Counselor

 Please personally describe the resonable accommodation(s) requested


In addition to submitting this online form by pressing the "submit" button below you will need to
print the Authorization for Exchange of Confidential Information Form and mail it to:
McMurry University Disability Services - McM Station Box 657 - Abilene, TX 79697
or bring it by the Disability Services office in Old Main, Suite 102.  Thank You!

     

You may also print this form and mail it to the address listed above.
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