Home Enroll at MGCCC Apply for Admission Students with Disabilities Obtain Accommodations Disability Accommodations Request Authorization Type*First-timeReauthorizationSemester*SpringSummerFallSemester Year*Campus*Bryant Center at TraditionJackson County CampusMaritime Training AcademyHarrison County CampusKeesler CenterNaval Construction Battalion CenterWest Harrison County CenterPerkinston CampusGeorge County CenterName* First Middle Last MGCCC ID (M) NumberDate of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter Email Confirm Email Phone*Major*Documentation of DisabilityMedical Diagnosis/Description of Disability*Accommodations Requested* Audio Books Use of Assistive Software Alternate Test Setting Alternate Test- Audio Alternate Test- Braill Allow use of calculato Printouts on colored paper Allow use of Calming Technique Allow use of Digital Books Dietary Restrictions Drinks/snacks during class Allow Dictionary/Thesaurus Extended time in-class assign. Allow use of Electronic Device Extended Time-Quiz/Test Time/Half Extra copy of Textbooks Allow Frequent breaks Face Student when Speaking Handicap Accessible Dorm Provide Instructors notes Allow use of Interpreter Utilize Learning Lab Student Cannot Use Scantron Peer Note Taker Provide Oral Direction Use Colored Overlay/Pens Private Dorm Room Preferential Seating Provide Quiet Place to Test Orally Read Test Questions Service Animal Change sitting/standing Extra time to and from class Allow Tinted Glasses Allow use of recording device St. to type notes/assignments Verbal Que to complete task Allow virtual proctoring Provide written directions Wheelchair Accessible Use Large Print Extra Scratch Paper OTHER Other Accommodations Requested*Upload Documentation FilesPlease upload all supporting documentation. Drop files here or Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, xls, xlsx. VerificationHealthcare Contact* I give permission to Special Populations/Student Disability Services to contact my diagnosing healthcare professional to verify my eligibility for educational accommodations. I understand that this permission extends to the verification process only.Eligibility* By completing and signing this intake application, you are voluntarily disclosing your disability and does not necessarily confirm your eligibility status for services or accommodations. You also understand that the verification process may take several weeks; depending upon the appropriateness of the documentation you have submitted.Confidentiality* In addition, you understand that all information submitted to this office is to be completely confidential and used only in conjunction with this institution’s commitment and obligation to students with disabilities. The documentation you submit will only be used by this office.Release of Information* I hereby give Support Services permission to talk to my instructors, other college officials, and/or related agencies about my needs as they relate to my disability. This Authorization is valid for my total period of enrollment at Mississippi Gulf Coast Community College.Digitally Sign*Type your full name.Mississippi Gulf Coast Community College is an Equal Opportunity Employer and welcomes students and employees without regard to race, religion, color, national origin, sex, age or qualified disability in its programs and activities. For further information, contact the Compliance Officer, P.O. Box 609, Perkinston, Mississippi 39573, telephone number 601-528-8735, email address firstname.lastname@example.org .