I am requesting (check all that apply) * Housing Accommodations Dining Accommodations First Name * Last Name * Address * City * State * Zip Code * Phone Number (xxx) xxx-xxxx * Email (do NOT use addresses issued by high school/previous college) * Date of birth (Month/Day/Year) * Banner ID * Enrollment Date * Fall 2022 Spring 2022 Fall 2023 What type of housing and/or meal accommodations do you require? * Explain how the stated request above relates to your disability * Please provide acceptable alternatives if the accommodation is not possible * Are you currently under a doctor's care relating to your request? * Yes No If yes, please explain Are you taking any prescribed medications (housing/dining related) * Yes No If yes, please explain I authorize the housing/dining accommodations review committee to receive information from the provider below, specific to this request. * Yes I authorize my provider to discuss my condition(s) with the Director of Accessibility Services. * Yes I understand that all documentation is maintained confidentially. * Yes Name of provider * Provider Phone Number (xxx) xxx-xxxx * Provider Fax Number (xxx) xxx-xxxx * Provider Address * Provider City * Provider State * Provider Zip Code * Attach Medical Provider form * Upload More informationFiles must be less than 2 MB. Allowed file types: gif jpg jpeg png pdf. Submit
