Request for Services

Student Information

This form is for students who have been fully admitted to the University. Please do not enter your information if you are a prospective student.

First Name

Last Name

Middle Name

Preferred Name

GCID

Your ID will begin with 911

Bobcats Email

Please use your bobcats.gcsu.edu issued email address.

Student Phone Number

Do you receive Vocational Rehabilitation services?

Are you a veteran?

Are you a new student?

Are you a transient student?

Specific Accommodation Information

Your diagnosed disability falls into the following category

How your disability/ies affect you both outside and inside the classroom, including testing and studying situations:

Please list/describe any services/accommodations you previously received

Please list the accommodations you are interested in requesting at Georgia College.

Disclaimer: A submitted Request for Services and documentation is not a guarantee of accommodations.

Authorization to Release Information to the Regents Center for Learning Disorders

All documentation will be sent to the Regents' Center for Learning Disorders (RCLD) for review. The RCLD sets the standard for post-secondary documentation requirements to determine eligibility for appropriate academic accommodations. The RCLD is part of the Board of Regents, the governing body for all public colleges and universities in Georgia.

RCLD Release

I hereby authorize Georgia College Student Disability Resource Center located at 231 West Hancock Street/Campus Box 123 in Milledgeville, GA 31061 to:

Release the following information: psychological, neuropsychological, and other evaluations and medical documentation needed for consideration of the extension of academic accommodations to:

Regents Center for Learning Disorders
Georgia Southern University
PO Box 8019-Cone Hall
Statesboro, GA 30458

Authorization to Communicate Information

If you would like us to be able to communicate with someone about your accommodations and interactions with the Student Disability Resource Center Staff, you will have to have a FERPA Release on file with the Registrar's Office.

Do you have a FERPA Release on File with the Registrar's Office?

For more information about FERPA, visit https://www.gcsu.edu/registrar/ferpa-student-rights. To fill out a FERPA Release, visit https://www.gcsu.edu/sites/files/template-1/ferparequestform13.pdf Please return your completed FERPA Release to the Registrar's Office.

Upload supporting document(s)

Please upload documents in Word or PDF format. Do not upload password protected documents. Please remove all passwords before uploading. Documents should include a letter from your physician and/or psychiatrist, and copies of any psychological evaluations, IEP/504 plans from high school and confirmation of accommodations on the SAT/ACT.

Request for Services

Student Information

Specific Accommodation Information

Authorization to Release Information to the Regents Center for Learning Disorders

Authorization to Communicate Information

Document Information