Accomodations Request Form

First Name

Middle Initial

Last Name

Mid-State Student ID Number

Date of Birth

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

At which Mid-State location do you take the majority of your classes?

Wisconsin Rapids campus

Stevens Point campus

Marshfield campus

Adams County Center

Other

May we leave a message?

Yes

Which describes your student status?

New student in the application process

Current student

Which semester are you requesting accommodations for?

Current semester

Upcoming June semester

Upcoming August semester

Upcoming December semester

Upcoming January semester

Which of the following are you requesting accommodations for?

GED (Mid-State does not approve GED accommodations but will assist you in requesting them)

Accuplacer

A Mid-State course

I'm not sure

Please describe the services you are requesting.

How will you submit your documentation?

Mail to Disability Services at Mid-State Technical College, 500 32nd Street North, Wisconsin Rapids, WI 54484

Email to patti.lloyd@mstc.edu

Fax to 715.421.5561

Hand deliver to Mid-State Student Services & Information Center in Wisconsin Rapids, Stevens Point, or Marshfield

Other: (describe below)

If other, how will you submit your documentation?

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