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Accommodation Request Form
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Student Information
Please enter your information
First Name
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Last Name
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Middle Name
Preferred Name
Pronouns
Student ID
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Email
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Phone Number
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High School Attended
Year of Graduation
Month and Year of Enrollment
Expected to take classes on the following campus(es)
Bedford
Lowell
Online
Disability and Accommodation Information
Diagnoses:
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Attention Deficit/Hyperactivity
Autism Spectrum Disorder
Brain Injury
Communication
Hearing
Intellectual Disability
Medical (Please Specify Below)
Mobility (Please Specify Below)
Psychological (please specify below)
Specific Learning Disability (Please Specify Below)
Vision
Other (please specify below)
Temporary
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Please list any services or accommodations you think you will require as a result of your disability:
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Upload supporting document(s)
Document Information
Document Title
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File
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Maximum file size: 10240kb
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