Housing and Dining Accommodation Request Form

I am requesting (check all that apply)

Title
Are you currently under a doctor's care relating to your request?
I authorize the housing/dining accommodations review committee to receive information from the provider below, specific to this request
Are you taking any prescribed medications (housing/dining related)?
I authorize my provider to discuss my condition(s) with the Director of Accessibility Services
I understand that all documentation is maintained confidentially?
One file only.
768 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.