Disability Services Medical Request Form
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1Disability Services
Medical Request Form
Please print all information is a legible manner.
Name
: ________________________________________________________________________________
Student ID No
.:_________________________________________________________________________
DOB
: _________________________________________________________________________________
Home Address
:
Street:
_________________________________________________________________________
City/State
: ______________________________________________________________________
Residence Hall
___________________________________________________________________________
Room
__________________________________________________________________________
Home Telephone
: ______________
Cell Telephone
Email address:
:
_______________
________________
Major:
Freshman
Sophomore
Junior Senior
_______________
Accommodation Requested (be specific and attach relevant documentation)
Diagnosis
: _____________________________________________________________________________
Diagnostician/Treating Physician or Mental Health Professional
:
________________________________________________________________________________________
Address:
_______________________________________________________________________________
Telephone number
: ______________________________________________________________________
Email address
: __________________________________________________________________________
_______________________________________
___________________________________
Student Signature
Date
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Parent category: Legal