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Merrimack Accommodation Request Form
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Student Information
Please enter your information
First Name
(Required)
*
Last Name
(Required)
*
Middle Name
Student ID
(Required)
*
Email
(Required)
*
Please use your Merrimack email address
Phone Number
(Required)
*
Student Status
FR
SO
JR
SR
GR
GN
UN
Deposited Student Starting Classes Summer 2019
Deposited Student Starting Classes Fall 2019
FF
Affiliations
Athlete
Compass
First Generation
Honors
International
Promise
Transfer Student
Veteran
Specific Accommodation Information
My diagnosed disability falls into the following category
(Required)
*
How does your disability affect you academically?
(Required)
*
How does your disability affect student life in general, like taking tests and studying?
What types of accommodations have been helpful to you in the past?
What types of accommodations are you requesting?
Option for First Year Experience Course Taught by ASO Staff Member
If you are an incoming first-year student, would you like to receive information about being placed in a First Year Experience course taught by an Acessibility Services Office staff member?
Option for First Year Experience Course Taught by ASO Staff Member
Yes
Option for First Year Experience Course Taught by ASO Staff Member
no
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