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?

Hometown, Home State

Parking - More information if late request:

After August 15 - If you missed the due date for Medical Parking 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 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 or you must be on the waitlist, 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 explain in specific detail what type of housing you are requesting

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

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)

What barriers will your requested accommodation(s) remove in order for you to be successful in living at Merrimack?

Housing- More information if late request:

If you missed the 2021-2022 due date 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)

Attach Documentation

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

Please prove you are not a robot

Merrimack Accommodation Request Form

Student Information

Specific Accommodation Information