Merrimack Accommodation Request Form Powered by Symplicity

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Student Information

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First Name*:

Last Name*:

Middle Name:

Student ID*:

Email*:

Please use your Merrimack email address

Phone Number*:

Student Status:

Affiliations:

My diagnosed disability falls into the following category*:

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?:

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