Dear Prospective Student:

Thank you for your interest in the Services for Students with Learning Disabilities (SSLD) program at Murray State University. Enclosed you will find a brochure that tells about the services that are available to students with documented learning disabilities. In order for us to provide you with the accommodations you require, we will need the following information:

1. A completed SSLD application form.

2. A copy of your ACT Scores.

3. A current copy of the psychological and educational evaluation that diagnoses your learning problems.

4. A recent photograph (this helps us to remember you)!

5. A one-page essay (in your own words without help). Please answer the five questions on the back of the application.

For further information about our program, please visit our website at www.murraystate.edu/ssld. You will find information about learning disabilities, official registration forms, tips, directions and important dates. If you are interested in a tour of the campus, the Office of School Relations will be happy to schedule one for you. They can be reached at (800) 272-4MSU. Let them know that you would like an appointment to meet my staff and me, and they will include an appointment with the SSLD Office in your itinerary.

If you have any questions, please feel free to call me at (270) 809-2018. We look forward to hearing from you.

Sincerely,

Cindy Clemson, Coordinator

Services for Students with Learning Disabilities (SSLD)

**Student requesting Project Mentor for next year must send in their application and information as soon as possible. Only 50 new students will be accepted into Project Mentor beginning with the 2007-2008 school year.

RELEASE FORM

I, the undersigned, give the coordinator/assistant coordinator of the Services for Students with Learning Disabilities program permission to release and/or obtain information concerning my diagnostic testing, grades, and other information to/from instructors, parents, assigned tutors, vocational rehabilitation counselors, and Murray State University administrative staff as necessary. This information will be used to assist the SSLD staff in providing services to me. I understand that these individuals will keep this information confidential.

Signature ________________________________

Date ____________________________________

First Floor Housing Information

Kentucky law requires that students who have a disability, or a sensory, cognitive, or neurological deficit or impairment, or a learning disorder, minimal brain dysfunction, dyslexia, pervasive developmental disorder, autism, or Asperger Syndrome be given priority for the first floor housing assignments. If you have a disability or condition, as noted above, and desire a first floor housing assignment, contact the Coordinator for Administrative Services at the Murray State University Housing Office, phone number: 270-809-2310, to request a “Housing Request Re: First Floor Housing Assignment”. Please note that first floor housing assignments are only available in Clark, Richmond, Franklin, and Springer Colleges. (Springer is available for female students only.)

Services for Students with Learning Disabilities Application

YOUR INFORMATION

Please answer all questions completely. Please print or type clearly.

Date ___________________________

Month/Day/Year

Name _______________________________________________________________________

First Middle Last

M#__________________________

SSN _______-_______-_______ Date of Birth ______ /______ /______ Gender  M  F

Permanent Home Address ______________________________________________________

Street

_______________________________________________ _____________ _____________

City State Zip Code

Home Phone: ( ______ ) _______-________ Cellular Phone: ( ______ ) _______-________

Age ____________________

EDUCATION

High School Information

Please provide information on the high school from which you graduated.

Name of High School ___________________________________________________________

Graduation Date _________________________ GPA _______________________________

Date Expected to Enter College _______________ Proposed Major ____________________

Date of Student’s Last Educational Evaluation _____________________________________

Most Recent or Highest ACT Scores:

ENG _____ MAT _____ REA _____ SR _____ Composite _____

College Information if Transferring

Please list ALL colleges/universities previously or presently attended/attending (most recent first.)

Name(s) of College(s) Dates of Attendance

1. _____________________________________________ __________________________

2. _____________________________________________ __________________________

LEARNING DIAGNOSIS INFORMATION

Have you been diagnosed with a learning disability/disorder or ADHD?  Yes  No

If yes, what was the diagnosis: ___________________________________________________

By whom: ___________________________________________________________________

Title First Name Last Name

_____________________________________________________________________________

Street City State Zip Code

Date of diagnosis: ______________________________________________________

Were you in a learning disabilities program in high school?  Yes  No

What courses do you find most difficult? __________________________________________

Which of the following academic supports, if any, have helped you in the past?

_____ Books on Tape _____ Oral exams

_____ Computer/Spell Checker _____ Scribe for exams

_____ Extra time on exams _____ Tutoring

_____ Note-takers Other: ______________________________

Which of the following areas are problematic for you?

_____ AD(H)D _____ Organizational skills

_____ Difficulty reading _____ Study skills

_____ Mathematics _____ Test-taking strategies

_____ Note-taking _____ Written language

Are you currently a client of Vocational Rehabilitation?  Yes  No

If yes, who is your Vocational Rehabilitation Counselor?

_____________________________________________________________________________

Name Telephone Number

FAMILY INFORMATION

Father’s/Guardian’s Name _____________________________________________________

Permanent Home Address ________________________________________________________

Street

_______________________________________________ _____________ _____________

City State Zip Code

Home Phone ( ______ ) _______-________ Cellular Phone ( _______ ) ________-________

Name of Employer _______________________________ Job Title ______________________

Work Phone ( ______ ) _______-________ E-mail address ____________________________

Mother’s/Guardian’s Name _____________________________________________________

Permanent Home Address ________________________________________________________

Street

_______________________________________________ _____________ _____________

City State Zip Code

Home Phone ( ______ ) _______-________ Cellular Phone ( _______ ) ________-________

Name of Employer _______________________________ Job Title ______________________

Work Phone ( ______ ) _______-________ E-mail address ____________________________

Stepparent/Guardian’s Name ____________________________________________________

Permanent Home Address ________________________________________________________

Street

_______________________________________________ _____________ _____________

City State Zip Code

Home Phone ( ______ ) _______-________ Cellular Phone ( _______ ) ________-________

Name of Employer _______________________________ Job Title ______________________

Work Phone ( ______ ) _______-________ E-mail address ____________________________

If you do not live with both parents, with whom do you reside permanently?

_____________________________________________________________________________

Name Relationship

ESSAY

On your own, please answer the following questions on a separate sheet of paper:

1. Please describe yourself.

2. Please describe how your disability/disorder affects you.

3. Why do you want to attend college?

4. What were the deciding factors in choosing Murray State and our department?

5. What academic areas do you like best and why?

Please send all materials to: Cindy Clemson, Coordinator

Services for Students with Learning Disabilities

Murray State University

423 Wells

Murray KY 42071

Murray State University

Project Mentor Information Sheet

Project Mentor is an academic support unit that offers enhanced services to students diagnosed with a learning disability, attention deficit disorder, traumatic brain injury, or other related disorders. Students receive individualized assistance with learning effective strategies for organizing and studying course-related materials. Each student enrolled in Project Mentor is assigned to work with a trained Academic Mentor on a regular weekly basis (usually 2-3 times per week). Sessions with the Mentor may include any of the following: writing skills, self-advocacy skills, study skills, social skills, and referral to other campus resources.

Since the creation of Project Mentor, graduation rates of MSU students with learning disabilities have increased from 5% to 55%. These statistics proved that students who take advantage of the services are finding success at the university level. We recommend that all freshmen and sophomores have a mentor for at least two hours per week. Mentors must attend mandatory training sessions to ensure that our student may have the best available assistance.

Fees are based on the number of hours each week the student meets with his/her Academic Mentor. Fees are billed at the beginning of the semester and are as follows:

1 hour per week ($225.00 per semester)*	4 hours per week ($900.00 per semester)
2 hours per week ($450.00 per semester)	5 hours per week ($1,125.00 per semester)
3 hours per week ($675.00 per semester)	6 hours per week ($1350.00 per semester)
* 1 hour per week must by approved by SSLD Coordinator

In addition to mentor services, we provide specialized sections of the following classes for course credit: Freshman Orientation (FYE 098), College Study Skills (REA 120), and Advanced College Study Skills (REA 121). These sections are mandatory for students who are enrolled in Project Mentor. The Project Mentor program and these specialized courses are offered in addition to accommodations required by law.

To request this service please fill out the Project Mentor Request Form and send it to our office along with your application.

If you have any questions, please contact:

Mary Jo Wallace, Project Mentor Supervisor

SSLD Office

Murray State University

423 Wells

Murray KY 42071

Phone: 270-809-4340

Email: projectmentor@murraystate.edu

Project Mentor is a component of the SSLD Office, 423 Wells, Murray KY 42071.

Phone (270) 809-2018 Fax (270) 809-4339

Project Mentor Request Form

Student Name: ___________________________________ SS#: _________________________

(Please Print)

Phone Number: _________________________ email: ______________________________

Cell Number: ___________________________

_____ Spring semester _____ Summer semester _____ Fall semester 20_____

Subject(s) with which you will need assistance: ____________________________________

____________________________________

Would you like to request a specific tutor: _______________________________________

Please indicate how many hours per week by checking one of the following:

_____ 1 hour per week ($225.00 per semester)* _____ 4 hours per week ($900.00 per semester)

_____ 2 hours per week ($450.00 per semester) _____ 5 hours per week ($1,125.00 per semester)

_____ 3 hour per week ($675.00 per semester) _____ 6 hours per week ($1,350.00 per semester)

* 1 hour per week must be approved by LD Coordinator

___________________________________ _____________________

Signature of Student Date

___________________________________ _____________________

Signature of Responsible Party Date

(Circle one) Parent VRC Other

Name of VRC (if applicable) _______________________________________

NOTE:

Failure to meet with your assigned mentor will not result in a refund for unused hours. If the Department of Vocational Rehabilitation provides assistance, failure to use the requested hours could affect the amount of mentoring authorized for subsequent semesters.

******************************************************************************

Office use only:

Tutor(s) assigned: _______________________________________________________________

Date Assigned: ______________________

Date Billed: _________________________ Amount Billed: _____________________________

Project Mentor is a component of the SSLD Office, 423 Wells, Murray KY 42071.

Phone (270) 809-2018 Fax (270) 809-4339