Please complete and return the Parking Accommodation Request Form to the Disability Services office, room 316 Clapp Library. The applicant fills out the first section. A doctor or other certified health care professional completes the second section.

Upon receipt of this completed form, Disability Services will make a recommendation to Campus Police that may include parking in a closer lot or use of disability/accessible parking spaces.

I. To be completed by the Parking Accommodation Applicant

1. Name (please print): __________________________________________________________

2. Campus Dorm or Work Location if any:___________________________________________

3. Phone:__________________________Circle: Student Staff Faculty Guest

4. If requesting a closer lot (s), please specify which lot(s)

5. If requesting disability/accessible parking space access, please specify which location(s)

6. Car Info: Color __________Make______________Model________________Year_________

License Plate Number_______________________State Issued_____________________

Signature: ___________________________________________ Date: ____________________

II. To be completed by a Medical Professional

1. Name (please print): _________________________________Title/Credentials____________

2. Address:_________________________________________Phone:_____________________

3. Diagnosis___________________________________________________________________

4. Prognosis (temporary or permanent condition, if temporary-how long?)__________________

5. Walking Limitations__________________________________________________________

6. Recommendations____________________________________________________________

Signature: _____________________________________________ Date: __________________