Registration/Self-Identification Form (Students with Disabilities)

REGISTRATION/SELF-IDENTIFICATION FORM

STUDENTS WITH DISABILITIES

It is the goal of Moody Bible Institute to ensure all college services, activities, facilities, and privileges are accessible to qualifed persons with disabilities. Appropriate accommodations will be made on an individualized basis. It is the responsibility of persons with disabilities, however, to seek available services and make their needs known to the Assistant Dean, Student Resource Center (SRC).

If you believe you are an individual with a disability who may require accommodations from Moody Bible Institute, please complete this form and use the submit button below. The information provided will only be used by the Assistant Dean to aid in determining accommodation needs. You may also make an appointment with the link at the bottom of the form.

First Name *

Last Name *

Date *

Student ID# *

Phone *

Email Address *

Re-enter Email Address *

Class status? *

Campus location? *

Chicago

Michigan

Washington

Distance Learning

Live on campus? *

Yes

No

Date of entry MBI? * +

Expected date of graduation? * +

Major? *

Indicate your area of disability: *

For futher information, contact:

Sam Murphy

Assistant Dean of Disability Support Services/Student Resource Center

sam.murphy@moody.edu

820 N. LaSalle Blvd.

Chicago, IL 60610-3284

Phone: (312)-329-2177

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