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Accommodation Request Form

* indicates a required field

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

Preferred NameRequired *

Pronouns

Student IDRequired *

EmailRequired *

Phone NumberRequired *

High School or Equivalency Program AttendedRequired *

Year of High School Graduation or Equivalency CompletionRequired *

Graduated with (diploma, HiSET, GED)Required *

Semester of Enrollment at MCC

Expected to take classes on the following campus(es)

Bedford Lowell Online

Disability and Accommodation Information

Diagnoses:Required *

Attention Deficit/Hyperactivity Autism Spectrum Disorder Brain Injury Communication Hearing Intellectual Disability Medical (Please Specify Below) Mobility (Please Specify Below) Psychological (please specify below) Specific Learning Disability (Please Specify Below) Vision Other (please specify below) Temporary

Please specify:

Please list any services or accommodations you think you will require as a result of your disability:Required *

If you are unsure, you can put "want to discuss," "not sure," etc.

Upload supporting document(s)

This may include evaluations (neuropsych, educational, medical, etc.) and/or the SASS provider form. IEP and 504 plans are helpful information, but will not meet the requirement. If you have any questions or concerns about documentation, please submit without and reach out to the office.

Document Information

Document Title

FileRequired *

Maximum file size: 10240kb

Description