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Public Accommodation Request
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Student Information
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Application date
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First Name
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Last Name
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Middle Name
Preferred Name:
What are your preferred pronouns:
Student ID
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Email
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Please use your university issued email address
Phone Number
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Specific Accommodation Information
My diagnosed disability falls into the following category
Required
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When were you diagnosed (month and year)?
Do you have dietary limiations due to a disability?
Do you have dietary limiations due to a disability?
Yes
Do you have dietary limiations due to a disability?
No
What limitations are related to your disability (list of foods unable to consume)?
Does the housing environment impact your disability?
Does the housing environment impact your disability?
Yes
Does the housing environment impact your disability?
No
How does the housing environment impact you and to what extent?
How does your disability affect you academically?
Required
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Are you impacted by online instruction:
Are you impacted by online instruction:
Yes
Are you impacted by online instruction:
No
Please describe the impact you experience when in a virtural environment:
How does your disability affect student life in general, like taking tests and studying?
What accommodations have you used in high school or college?
What accommodation(s) are you requesting?
What accommodations are you requesting in a Clinical/Practicum/Student Teaching or other environment?
Can you meet the technical standards of your program of study if provided reasonable accommodations?
Can you meet the technical standards of your program of study if provided reasonable accommodations?
Yes
Can you meet the technical standards of your program of study if provided reasonable accommodations?
No
Are you a high school student participating in a Mercer program?
Are you a high school student participating in a Mercer program?
Yes
Are you a high school student participating in a Mercer program?
No
Consent and Confidentiality
Required
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By completing and signing this form, the signer is voluntarily disclosing a disability and requesting accommodations. Disclosure does not confirm eligibility status for services or accommodations. The Access and Accommodations office will make every effort to quickly review all requests but be aware that this process can take time depending upon the comprehensiveness and currency of documentation submitted. All information provided is kept confidential and is used only for the purposes of meeting the universities commitment to serving students with disabilities.
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