Please PRINT OUT and SIGN this form. Attach your documentation and bring both when you make your appointment with a disability specialist. Appointments can be made in person in KSC 258 or by calling Mary Kaye at 218-726-6130. This form cannot be saved or sent electronically.
Name: First Middle Last
UM ID# Your UMD E-mail Birth Date
Local Address: Street City
State Zip Phone
First semester enrolled at UMD Major Transfer student
Previous College(s) attended Credits
Previous College(s) attended Credits
Prospective Student's Academic Information
Anticipated Enrollment Date (Semester and year)
Previous college attended Credits
Check all that apply:
Briefly describe your disability, including date of onset and diagnosis.
Current medications and side effects if any:
Are you registered with Rehabilitation Services or State Services for the Blind?
What accommodations have you used in the past?
What specific accommodations would you like to request?
List the accommodations you have requested (or will) for University Housing (e.g., wheelchair accessible, visual alarms, single room):
I understand that I must provide documentation of a diagnosed disability in order to use disability accommodations on a continuing basis. Without a documented disability, I am not eligible for disability accommodations on a continuing basis.
Documentation must be provided by a licensed professional who has relevant training and experience diagnosing and treating the reported condition and is unrelated to the individual being evaluated. All documentation needs to be typed on letterhead, dated and signed. The documentation should include the following information:
I also understand that the University reserves the right to deny accommodations not supported by my disability documentation.
Student Signature___________________________________ Date ___________
For more information, see Documentation
OPTIONAL: Authorization for Release of Information to Parents/Guardians
All disability-related information is kept confidential, as required by law, and cannot be shared without your written consent. The form below authorized DR to discuss otherwise confidential information with your parents, should they contact us. Completing and signing this part of the form is optional.
City, State, Zip
I understand that by signing this form, I authorize the Office of Disability Resources to discuss or release to the above parent/guardian information regarding my disability to assist in the determination and implementation of reasonable accommodations and to address educational planning needs.
I understand this authorization is voluntary and I may revoke this consent at any time through a written, signed, and dated request to the Director of Disability Resources. The revocation will not apply to action taken prior to the date.
Student Signature __________________________________________________ Date Signed ______________
Upon leaving the University, it is your responsibility to request your documentation to be returned to you.
All documentation will be destroyed seven years after the last date of enrollment.
Tennessen Summary: (Tenessen Warning) Disability Resources at UMD is asking you to provide information that is private under state and federal laws. This information is not considered official documentation, but will help determine if you are eligible for accommodations and, if so, which accommodations. You are not required to provide this information. However, without sufficient information, we will not be able to provide you appropriate accommodations. Access to this information will be limited to staff involved in the accommodation process.Â The release of this information to individuals or agencies without your consent is prohibited under state and federal laws.
I have been informed of this law and I authorize the collection of this private information.
Student Signature: ______________________________________ Date: ____________________
1. Print out and sign this request form.
2. Attach a copy of your documentation.
3. Mail or hand carry both documents to the Office of Disability Resources (258 KSC; 1120 Kirby Drive; Duluth MN 55812).
4. Make an appointment with a Disability Specialist by calling 218-726-6130 or inperson at KSC 258.
5. Bring your course schedule and class syllabi to your appointment with your Disability Specialist.