Montgomery College Disability Support Services Student Intake Powered by Symplicity

* indicates a required field

DIRECTIONS AND DISCLOSURES: Please answer the questions on this form to the best of your ability. Your answers are valuable and they help us understand how best to assist and accommodate you. Your information is confidential and secure. We will release information about you only with your written permission to do so. *If you wish to take a Workforce Development & Continuing Education (WD&CE) course and DO NOT have an M number please contact the main office at (240) 567-5058.

General Information

Please enter your information

First Name*:

Last Name*:

Middle Name:

Street Address*:

Example: 111 Main Street, Apt 102

Apt. #:

City*:

State*:

Zip Code*:

Primary Phone Number*:

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

Additional Phone Number:

Work Phone:

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

Cell Phone Number:

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

Home Phone Number:

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

Your Montgomery College Student ID (M12345678)*:

Birthdate*:

Email*:

Please use your Montgomery College issued email address

Are you a visiting summer 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.

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?*:

If Yes, name of school?*:

Have you graduated from high school?*:

What year did you graduate high school?:

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

Have you ever attended another college or university?:

When did you attend another college or univeristy?:

YYYY-YYYY

Where did you attend another college or university?:

School Name, City, State

Degree or credit hours acheived:

i.e. A.A. or 30 credits

Major?:

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.)

Or, you may click Submit and bring hard copies of your documentation to your appointment.