Accommodation Request

Please select any of the following areas in which you would like to discuss disability related impacts [Select all that apply]Required *

Classroom
Housing
Exams
Other

Are you requesting accommodations for Housing?Required *

Are you requesting accommodations for Housing? Yes Are you requesting accommodations for Housing? No

Please select each of the following accommodations that you are requesting.Required *

[select]Braille in room Elevator close proximity Emotional Support Animal Ground floor Horn alarm system Mini fridge Other (please describe below) Semi-private bedroom Single bedroom Strobe alarm system Wheelchair accessible room clear

{"display_name":"Please select each of the following accommodations that you are requesting.","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}

Are you requesting a meal plan accommodation?Required *

Are you requesting a meal plan accommodation? Yes Are you requesting a meal plan accommodation? No

Impact of food allergy or dietary restriction.Required *

Please select all that apply.

[select]Mouth - Itching, tingling, or swelling of lips, tongue, mouth Skin - Hives, itchy rash, swelling of face or extremities Gut - Nausea, abdominal cramps, vomiting, diarrhea Throat - Tightening of the throat, hoarseness, hacking cough Lung - Shortness of breath, repetitive coughing, wheezing Heart - Thready pulse, low blood pressure, fainting, pale, bluish skin tone Asthmatic - Could have a higher risk of severe reaction Other - Please explain below clear

{"display_name":"Impact of food allergy or dietary restriction.","hidden_field_name":"ms_field_2","init_id":"ms_field_2","init_link":"","has_autocomplete":false,"has_hierpicklist":null}

Please confirm.

I agree with this disclosure of my personal health information with relevant campus partners (i.e. Aramark).

I Agree