Accommodation Request

* indicates a required field

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Student IDRequired *

Sunbird Central EmailRequired *

@students.fresno.edu

Date of BirthRequired *

In case of emergency, please notifyRequired *

Please list emergency contacts name, relationship to you, and phone number

Disability Information:

Briefly describe your disabilityRequired *

Do you have a diagnosis? Can you describe symtpoms or struggles?

How does your disability affect you academically?Required *

In high school, did you have an IEP or 504 Plan?Required *

In high school, did you have an IEP or 504 Plan? Yes In high school, did you have an IEP or 504 Plan? No In high school, did you have an IEP or 504 Plan? Don't Know

If yes, which college or institution?Required *

Are you requesting accommodations because of a temporary disability or acute condition? Required *

i.e. concussion, accident, injury, surgery, etc?

Are you requesting accommodations because of a temporary disability or acute condition? Yes Are you requesting accommodations because of a temporary disability or acute condition? No

If this is a temporary disability, how long do you anticipate the need for accommodaitons?Required *

If this is a temporary disability, how long do you anticipate the need for accommodaitons? 2 Weeks or Less If this is a temporary disability, how long do you anticipate the need for accommodaitons? 1 Month If this is a temporary disability, how long do you anticipate the need for accommodaitons? 3 Months If this is a temporary disability, how long do you anticipate the need for accommodaitons? Other

If you selected other, please list the anticipated time for your accommodations request

Have you ever registered as a student with a disability at another college or university? Required *

Have you ever registered as a student with a disability at another college or university? Yes Have you ever registered as a student with a disability at another college or university? No

Is this the first time that you are requesting any kind of accommodations at Fresno Pacific University?Required *

Is this the first time that you are requesting any kind of accommodations at Fresno Pacific University? Yes Is this the first time that you are requesting any kind of accommodations at Fresno Pacific University? No

Accommodation Information

Are you requesting academic accommodations?Required *

Are you requesting academic accommodations? Yes Are you requesting academic accommodations? No

What type of academic accommodations are you requesting?Required *

Are you requesting housing accommodaitons?Required *

Are you requesting housing accommodaitons? Yes Are you requesting housing accommodaitons? No

What type of housing accommodations are you requesting?Required *

How does your disability affect you in a housing environment?Required *

Are you requesting meal plan accommodations? Required *

Are you requesting meal plan accommodations? Yes Are you requesting meal plan accommodations? No

If requesting meal plan changes, please check all that apply

Exemption Reductions Dietary Restrictions (food allergies, etc.)

For service animals only: Is this animal required because of a disability?

For service animals only: Is this animal required because of a disability? Yes For service animals only: Is this animal required because of a disability? No

List the type of service, work or task the animal has been trained to provide:

Are you requesting an Emotional Support Animal (ESA) accommodation?Required *

Please complete this form and submit it to Disability Access and Education office by the appropriate due date for the upcoming semester (July 1 for Fall, November 15 for Spring, April 1for Summer). Animals are not allowed in on-campus housing until the entire approval process is complete.

Are you requesting an Emotional Support Animal (ESA) accommodation? Yes Are you requesting an Emotional Support Animal (ESA) accommodation? No

For Emotional Support Animals only:

Attach completed Verification of Disability or other documentation of the need for an ESA accommodation in Housing. (See Service and Emotional Support Animal Policy information required.)

Animal NameRequired *

Animal TypeRequired *

Animal BreedRequired *

Animal SexRequired *

Animal Sex Female Animal Sex Male

Animal Size/lbs:Required *

For ESAs Only: How long have you had this animal? (Months or years)Required *

For ESAs only: Age of animal? (Months or years)Required *

For ESAs only: Spay/neuter date and facility (attach documentation):Required *

Date of last wellness visit to a licensed veterinarian

Do you have a city of Fresno dog license?Required *

Please note: a dog license will be required to be considered for approval of an ESA

For information on how to obtain a dog license, please visit the following link.

Do you have a city of Fresno dog license? Yes Do you have a city of Fresno dog license? No

For dogs only: City of Fresno dog license #:

City of Fresno Dog License Application

Physical description of animal (attach photo):Required *

Is the animal current on veterinary-recommended vaccinations?Required *

Is the animal current on veterinary-recommended vaccinations? Yes Is the animal current on veterinary-recommended vaccinations? No

Date of most recent vaccinationsRequired *

Button, Start Date - Pick Using Date Picker Widget Button, Start Date - Clear/Reset Selected Date

Format as: two digits for month, dash, two digits for day, dash, four digits for year (yyyy-mm-dd)

Animal Vaccination: Please Explain "No"Required *

Has the animal ever bitten or shown aggression toward people? Required *

Has the animal ever bitten or shown aggression toward people? Yes Has the animal ever bitten or shown aggression toward people? No

Documentation Required

Attach all current vaccination and spay/neuter records with office letter head below.

If applicable your city of Fresno dog license must also be attached.

ESA and SA

Please attach verification that the SA/ESA has all veterinary recommended vaccinations to maintain the animal’s health and prevent contagious disease.

Emergency Contact:

(If you are unable to care for your animal for one night or more)

Name:Required *

Primary phone:Required *

Address (street, city, state, and zip):Required *

Relationship to student:Required *

Understanding: Required *

have read and understand the Service Animal and Emotional Support Animal Policy and Agreement Service and Emotional Support Animal Policy

Yes

I affirmRequired *

 I affirm that the above information is true to the best of my knowledge and belief. I agree to cooperate fully if verification of the above statements is required in the future:

Yes

Student SignatureRequired *

Documentation

Upload supporting document(s)

This can be a health care provider's note/letter, diagnosis on a patient portal, proof of history of accommodations, etc. Please ask if you have questions.

Drop files here to upload

Release of Information

Do you consent to share your information with a specified person? Required *

Do you consent to share your information with a specified person? Yes Do you consent to share your information with a specified person? No

If yes, please list the full name of the individual you are consenting release of information toRequired *

Please indicate your relation to this personRequired *

Please provide the birthdate of the person (month and date)Required *

Do you have a second contact you would like to add for release of information?

Do you have a second contact you would like to add for release of information? Yes Do you have a second contact you would like to add for release of information? No

If yes, please list the full name of the second individual you are consenting release of information toRequired *

Please indicate your relation to the second personRequired *

Please provide the birthdate of the second person (month and date)Required *

I understand and consent to the following:Required *

I understand that by checking this box and submitting this form, I am waiving my rights of nondisclosure of these records under federal law only as to the persons/entities specifically listed. This release does not permit the disclosure of these records to any other persons or entities without my written consent as permitted by law.

I further understand that by not providing names above, I choose not to grant access to my disability information to anyone other than those stated in this disclosure.

I understand