Montgomery College Disability Support Services Student Intake

General Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Name

What is your preferred name, if any?

Street Address

Example: 111 Main Street, Apt 102

Apt. #

City

State

Zip Code

Primary Phone Number

###-###-####

Additional Phone Number

Your Montgomery College Student ID (M12345678)

Birthdate

Preferred Pronouns

Please tell us what pronouns you prefer that we use when communicating with you.

Email

Please use your Montgomery College issued email address

Are you a visiting student from another College/University?

Are you a Veteran?

Emergency Contact Person's Name

Emergency Contact Relationship

Emergency Contact's Primary Phone Number

Emergency Contact's Secondary Phone Number

Which campus will you be attending?

If you are taking classes on multiple campuses please select your "home" campus.
If you are taking online classes only, please select the campus that is nearest to you.
You can only select one campus.

When do you plan to take classes?

Please tell us what semester you plan to take classes (Spring 2022, Summer 2022, Fall 2022, etc.)

Are you planning to take credit classes or are you planning to take non-credit classes?

Credit classes are for degree-seeking, transfer-seeking, or certificate-seeking students. Non-credit classes are for personal development, professional development, or to obtain a certification or license.

Are you a Dual Enrollment program student?

Are you an Early College program student?

Disability Background

What is your diagnosed disability?

Select all that apply

Other

Describe your disability and how it affects your performance as a student?

Educational Background

Are you currently enrolled in high school?

Are you currently or have you ever been a student at Montgomery College?

Have you ever attended or are you currently attending another college or university?

Accuplacer & ESL Accuplacer Testing

The college-wide Accuplacer is a computerized self-paced, untimed test in reading, English, and math. The test is delivered in a multiple choice format and a calculator will pop-up as appropriate during the math portion.

If English is not your primary language, you should take the ESL (English as a Second Language) Accuplacer test. The ESL Accuplacer is also a computerized self-paced, untimed test. The test is delivered in a multiple choice format and includes a writing sample.

Do you require additional accommodations beyond extended time for the Accuplacer or ESL Accuplacer?

Documentation

Upload supporting document(s)

If available, you may upload your supporting documentation here. (Please upload one document at a time. A new upload box will appear when you have successfully attached a document.)