Student Accommodation Application

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Student Information

Please enter your information

First Name

Middle Name

Last Name

Preferred Name

Pronouns

Student ID

Please include the "S" when typing your student number.

Please use your Bruinmail email address

Date of Birth

Main Phone Number

Please enter your phone number in this form (xxx) xxx-xxxx

Alternate Phone Number

Primary Campus

Military/Veteran

What accommodations have you received in the past?

What accommodations are you requesting at this time?

My condition falls into the following category

Please describe how your condition impacts you in the classroom

Upload supporting document(s)