Public Accommodation Request

Student Information

Please enter your full name, student ID, and contact information.

First Name

Last Name

Middle Name

Student ID

Email

Please use your MMC-issued email address.

You may also include an alternative personal address where we will be able to reach you.

Phone Number

Preferred pronouns

Accommodation Description

All accommodations fall into three categories. Descriptions of each category are below. Select the category/categories that best relate to your requested accommodation(s). If you are requesting multiple accommodations, select the option that contains all the categories related to your request.

Academic- Accommodations that impact your experience in the classroom. (Examples: note taker, testing accommodations, Assistive Technology, etc.)

Housing- Accommodations in the residence halls. (Examples: de-lofted bed, fewest number of roommates, Dining Dollar review, etc.)

Assistance Animal- An accommodation to have an Assistance Animal accompany a student. If you are requesting to have the Assistance Animal live in a residence hall, please select "Assistance Animal and Housing"

What type of accommodations are you requesting

Specific Accommodation Information

Disability Category(ies)

List or describe specific diagnosis information

How does this disability affect you socially on campus

Do you use a wheelchair

Past accommodations received, if any

Will you require clear face masks to read other's lips?

Is there anything else you want to share about your disability that you have not addressed above?

Documentation

Specific supporting documentation must be provided for each individual request, and certain accommodations may require additional or specific documentation. (For example, some academic and housing accommodation requests may be supported by an IEP, 504 Plan, or a psychological evaluation, while other accommodations may require a letter from a qualified professional indicating specific needs and accommodation recommendations. Please see "Documentation Requirements" our How to Register page for more information. For Assistance Animal registration requests a doctor's note specifically stating the request for an AA is needed along with other pertinent information. Please see AA section for details.) Please note that MMC cannot distribute documentation to a third party or reissue it to students. Please maintain originals for your own records.

Upload supporting document(s)

Release of Accommodation and Disability-Related Information

I hereby grant MMC to release any of my academic, accommodation, and disability-related information to the following person(s):

Person 1: Name, Relationship, and Contact Information

Person 2: Name, Relationship, and Contact Information

Person 3: Name, Relationship, and Contact Information

Text Message Reminders

Would you like to receive text message reminders?

Text Message Disclaimer

By providing your phone number, you agree that the text messaging capability is predicated upon my service provider delivering the text message to me in a timely manner. I agree not to hold Symplicity responsible for missed messages and any pursuant damages. I further understand that there may be charges associated with the text messages, and these charges are ENTIRELY my responsibility.

Please provide a cell phone number

*Standard message data rates apply*

Electronic Signature