Student Accommodation Application

First Name

Middle Name

Last Name

Preferred Name

Pronouns

Student ID

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

Email

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

What accommodations have you received in the past?

What accommodations are you requesting at this time?

Please describe how your condition impacts you in the classroom

Upload supporting document(s)

Student Information