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MPCC Student Intake Form

Mid-Plains Community College Disability Services (MPCC DS) works with all aspects of the college and the communities we represent to provide opportunities for students with disabilities and enables them to fully participate in and enjoy the benefits of higher education. MPCC recognizes that disabilities reflect diverse characteristics and experiences and is an aspect of diversity integral to society. MPCC DS achieves individualized assistance by honoring the uniqueness of each student and through the provision of resources and services that promote academic success and self-advocacy skills. In addition, we collaborate with instructors, staff, and community members to create usable, equitable, inclusive, and sustainable learning environments.

Student Bio Info

Name

 

Address

 

Phone

 

Email

 

Date of Birth

 

Gender

 

Social Security Number

MPCC ID

0

Semester & Year

Degree received

 

Student Accommodation History

Student Disability Information

Disability

Disability Documentation

Student Area Supports

Student Signature (Type Name)

Date

7/12/2026

ID

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