Academic Adjustments and/or Auxiliary Aids Request Form

Academic Adjustments and/or Auxiliary Aids Request Form

Midwest Institute does not discriminate on the basis of disability status in admission or access to its programs and activities. Future students of Midwest Institute must notify the college in advance if special accommodations are needed so that these arrangements can be discussed with the Education Department. Requests for academic adjustments and/or auxiliary aids are based on mutual planning among the Director of Education, staff, and faculty. The arrangement of accommodations can take time and may require follow-up interviews. Please submit your request at the earliest possible date.
Requestor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Need for accommodation:
Please attach documentation of diagnosed learning disability: (diagnosis must be within the last 36 months)

Browse Files

Cancelof
Requestor's suggested accommodation:
Suggested accommodation by other agency or individual:
Request received by:

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Form will be submitted to Mrs. Pandolfo, Director of Education, Midwest Institute

4260 Shoreline Dr, Earth City, MO 63045 Phone: (314) 344-4440

You will be contacted regarding accommodation decision within 5-7 business days after submission
For Internal Purposes Only - Do Not Write Below this Line
I concur with the proposed accommodation:
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I wish to appeal the committee's proposal:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accommodation Approved:
Director of Education
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accommodation Approved:
Director
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: