Accommodation Request

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Student IDRequired *

Sunbird Central EmailRequired *

@students.fresno.edu

Date of BirthRequired *

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

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

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

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.)

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

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

Animal NameRequired *

Animal TypeRequired *

Animal BreedRequired *

Animal SexRequired *

Animal Sex Female Animal Sex Male

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

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.

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.

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