Merrimack Accommodation Request Form

My diagnosed disability(disabilities) falls into the following category (categories)

How does your disability affect you academically?

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?

Parking - More information if late request:

If you missed the deadline for Medical Housing requests (please view all deadlines on our website) would you like to share any circumstances that could aid in consideration of a reasonable accommodation? (for example, new diagnosis, late deposit to Merrimack, change in circumstances)

Please explain in detail why you require Merrimack parking (i.e. frequency of medical appointments, physical needs, etc.)

Alternative plan:

If this request were not able to be reasonably accommodated, what would be an alternatively reasonable solution? (For example, I will utilize Zipccar or Uber, the train and campus bus system, or a family/friend)

Please provide your current medical diagnosis and specific details as to why it requires accommodation(s)

Describe the functional limitation(s) of a major life activity you are experiencing as a result of your disability.

A functional limitation is an impairment in a person’s ability to function in a way that falls within the normal range for the activity (e.g., sleeping, breathing, climbing, walking)

Please share the specific housing accommodation(s) that you are requesting

(please note, accommodations cannot be based on other people in the room and/or specific buildings on campus)

Please explain how you have been able to meet these needs prior to this request.

If this request were not able to be reasonably accommodated or you must be on the waitlist, what would be an alternatively reasonable solution?

(For example, if a single room were not available, a double room rather than a triple room)

If this is a late request, please share more information

If you missed the deadline for Medical Housing requests, would you like to share any circumstances that could aid in consideration of a reasonable accommodation? (for example, new diagnosis, late deposit to Merrimack, change in circumstances)

Please describe your plan to care for the ESA and its daily needs

Please note: friends/roommates are not permitted to care for the animal.

Please describe your plan to buy food, pellets, etc.

Please describe your plan to bring the ESA to a veterinarian if necessary

Please describe your plan to bring your ESA if you are away from campus.

i.e. school breaks, home for the weekend, a school retreat. Please note: The animal cannot remain in the residence hall for any overnight duration of time without you

Please describe your secondary plan if you determine you can no longer care for the ESA.

Please describe why your needs cannot be met within current meal plans or existing adjustments offered by dining services.

Attach Documentation

For example: IEP, Neuropsychological Testing, 504 Plan, Doctor's Letter, ***If nonacademic - request cannot be completed without Medical Provider Form***

Merrimack Accommodation Request Form

Student Information

Specific Accommodation Information

Document Information