Self-Disclosure Form
Students who have been admitted to Mountwest Community and Technical College and
wish to receive accommodations from Disability Services are encouraged to complete
and submit this form. Once Disability Services receives your Self-Disclosure Form, we
will contact you to discuss accommodations for the upcoming semester.
Please return this form to advising@mctc.edu or return in person at the Student
Services front desk. You will also need to provide your disability documentation to the
Disability Services office in order to receive accommodations.
First Name:
___________________________________________________________________
Last Name:
___________________________________________________________________
942#:
___________________________________________________________________
Address:
___________________________________________________________________
City/State/Zip:
___________________________________________________________________
Phone Number:
___________________________________________________________________
MCTC Email:
___________________________________________________________________
Type of Disability and Accommodations Requested:
______________________________________________________
______________________________________________________
______________________________________________________
