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Disability Services Application

MacMurray College provides access and accommodations for eligible students with documented disabilities or functional limitations who intend to pursue coursework at MacMurray College. A variety of programs and services are available which afford eligible students with disabilities the opportunity to participate fully in core academic experiences through appropriate and reasonable accommodations. Completion of this form constitutes an agreement to apply for services with Disability Services and must be completed prior to obtaining services. In addition, the student rights and responsibilities as they pertain to Disability Services are described here.

If you would rather print out a copy of the form and hand it in to the Office of Disability Services at Henry Pfeiffer Library Room 103, you may use a PDF copy (PDF).

Fields marked with an asterisk (*) are required.

Student Information

Emergency Contact Information

Disability Information

Are you a Division of Rehabilitation Services client?*     

What is your documented disability?*


Do you take any medications that would affect your education?*     

Student Rights and Responsibilities


  • My participation in Disability Services shall be entirely voluntary.
  • Receiving support services through Disability Services shall not preclude me from also participating in any other course, program, or activity offered by the College or from receiving basic accommodations required by state and federal law.
  • All records maintained by Disability Services personnel pertaining to my disability(ies) shall be protected from disclosure and shall be subject to all other requirements for handling of student records.


  • I will provide Disability Services with the necessary information, documentation and/or forms (disability verification, medical verification, educational, release of information, and so forth) to verify my disability.
  • I will meet with Disability Services personnel to complete an Accommodations Service Contract.
  • I will meet with Disability Services personnel at least once per semester to update my Accommodations Service Contract and to pick up Accommodations Notification.
  • I will utilize Disability Services in a responsible manner. I understand that Disability Services uses written service provision policies and procedures which must be adhered to for continuation of services.
  • I will comply with the rules, standards, policies, and procedures set forth in The Maggie: A Student's Guide to MacMurray College, adopted and published by MacMurray College.

Personal information recorded on these forms will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the instructors, professionals, or other state or federal agencies; however, disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 USC 1232(g)).

Leave this field blank.