Mount Saint Mary College
Services for Students with Disabilities
330 Powell Avenue
Newburgh, NY 12550
Phone: 845-569-3115 Fax: 845-569-3135
Information and Accomodations Request Form

Contact Information (* Indicates Required Fields)
First Name:* Middle Initial: Last Name:*
Name you would like to be called (if different from above):
Address 1:*
Address 2:  
City:*    State:* Zip Code:*
Home Phone:*   Cell Phone:
Email Address:*
Email Address:* (Confirmation)
Date of Birth:* Age:* Gender:*
What is your current status at Mount Saint Mary College?*

Disability Information
What is your disability?
What disability accommodations are you requesting?
By pressing "Submit Request," I affirm that I have read and understand the MSMC policies and procedures regarding disability accommodations. I understand that the MSMC Services for Students with Disabilities office may need to contact the doctor or the other professionals who have provided documentation pertaining to my disability status or accommodations as explained in the MSMC policies and procedures for requesting accommodations.