Merrimack Accommodation Request Form

* indicates a required field

Student Information

This form needs to be completed by the student requesting the accommodations. Please fill in your information below:

First NameRequired *

Last NameRequired *

Middle Name

Merrimack IDRequired *

Merrimack Email AddressRequired *

Email address should end in @merrimack.edu

Phone NumberRequired *

Student Status

Affiliations

Athlete
Compass
First Generation
Honors
International
Promise
Transfer Student
Veteran

Specific Accommodation Information

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

Are you requesting Academic Accommodations?Required *

Are you requesting Academic Accommodations?

Are you requesting Academic Accommodations? Yes Are you requesting Academic Accommodations? No

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 and support have been helpful to you in the past?

What types of accommodations are you requesting?

Would you like to sign up to participate in the Activate Program?Required *

Activate supports our neurodivergent undergraduate students (Autism, Asperger's, NVLD). We provide success coaching, social events, peer mentoring, and career readiness support. By clicking Yes, you are committing to participate in this program.

Would you like to sign up to participate in the Activate Program? Yes Would you like to sign up to participate in the Activate Program? No

Which portions of the Activate Program will you be participating in?Required *

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What types of academic/social support did you utilize in high school?Required *

What types of academic/social support do you think that you'll need in college?Required *

What are you hoping to gain from being a part of Activate?Required *

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Are you requesting Nonacademic Accommodations?Required *

(Parking, Housing, Dietary)

Are you requesting Nonacademic Accommodations? Yes Are you requesting Nonacademic Accommodations? No

Are you requesting Medical Parking Accommodations?Required *

Are you requesting Medical Parking Accommodations? Yes Are you requesting Medical Parking Accommodations? No

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 describe the length of time in which you require this accommodation

Please describe the length of time in which you require this accommodation Temporary
Please describe the length of time in which you require this accommodation Spring Semester Only
Please describe the length of time in which you require this accommodation Fall Semester Only
Please describe the length of time in which you require this accommodation The Upcoming Academic Year

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)

Are you requesting Dietary Accommodations?Required *

Are you requesting Dietary Accommodations? Yes Are you requesting Dietary Accommodations? No

Are you requesting Medical Housing Accommodations?Required *

Are you requesting Medical Housing Accommodations? Yes Are you requesting Medical Housing Accommodations? No

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

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

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 requestingRequired *

(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.Required *

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

(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 informationRequired *

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)

Are you requesting an Emotional Support Animal?Required *

Are you requesting an Emotional Support Animal? Yes Are you requesting an Emotional Support Animal? No

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

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

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

Please describe your plan to bring the ESA to a veterinarian if necessaryRequired *

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

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.Required *

I confirm I've discussed with my medical provider the benefits and limitations of owning an ESA in the college environmentRequired *

I confirm I've discussed with my medical provider the benefits and limitations of owning an ESA in the college environment Yes I confirm I've discussed with my medical provider the benefits and limitations of owning an ESA in the college environment No

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

I confirm I've discussed with Sodexo the various dietary options that already exist or can be adjusted through dining services.Required *

I confirm I've discussed with Sodexo the various dietary options that already exist or can be adjusted through dining services. Yes I confirm I've discussed with Sodexo the various dietary options that already exist or can be adjusted through dining services. No

Medical Provider Form Status:Required *

Medical Provider Form Status: Attached
Medical Provider Form Status: Already Submitted via email, mail, or fax
Medical Provider Form Status: Will submit later via email, mail, or fax (please submit as soon as possible in order to have a completed application)

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