Disability Services Request Form

Minnesota State College Southeast is asking you to provide private information in order to process your Special Needs/Support Services form. This information will be used to update your academic record. You are not legally required to provide this information; however, the college may not be able to effectively process your request if you do not provide sufficient information. Access to this information will be limited to school officials, including faculty who have legitimate educational interests in the information. Under certain circumstances, federal and state laws authorize release of private information without your consent: to other schools in which you seek or intend to enroll, or are enrolled; to federal, state or local officials for purposes of program compliance, audit or evaluation; as appropriate in connection with your application for, or receipt of, financial aid; if the information is sought with a court order or subpoena; or as otherwise permitted by other state or federal law.

This is to inform Minnesota State College Southeast that I am requesting assistance from the area of Disabilities Services because my history indicates a need for services unique to me.

I am requesting a conference to address my specific needs and review the services available to me.

I understand it is my responsibility to provide documentation of my specific needs.

I understand this disclosure is given voluntarily, and the information will be used to help me develop a plan to be more successful while attending MSC Southeast.

Date: 8/5/2020
Campus you plan to attend: