Please contact the DSC at either dsc-usm@maine.edu or at 207-780-4706 with any questions. Name * What are your pronouns? @maine.edu Email Address * What is your date of birth? * Phone number * Would you like to list an emergency contact? * Yes No Name of emergency contact Relationship to emergency contact Phone number of emergency contact When do you want accommodations to begin? * Immediately Fall Spring Summer What is your student status? * Incoming First Year Continuing Student Incoming Transfer Student Summer / Intern Please select all accommodations you are requesting: * Room with Close Proximity to Bathroom Lower or First Floor Room Assignment Single Room Room Equipped with Visual Emergency Signals Other Explain more about the "Other" option selected Please explain more about the "other" option. Please list any residential programs in which you currently participate / want to participate in in the future (Examples: Living/Learning Communities, Honors, Russell Scholars): * Please describe your disability. What barriers do you anticipate experiencing or have experienced in the residence hall? * How will accommodations mitigate symptoms and provide equal access for you? * Please provide any additional information you would like the Housing Accommodations Committee to consider when reviewing your request: I authorize the University of Southern Maine's Disability Services Center to speak with licensed professional(s) as needed to facilitate a determination of my request. Information discussed must be limited to the disability recorded in this request. * Yes No I also give permission for the University of Southern Maine's Disability Services Center to disclose my personal information as necessary to other USM departments to ensure an appropriate room assignment (examples: Office of Residential Life, Facilities). * Yes No Internal use