Temporary Accommodations Request Form
Name
*
First Name
Last Name
Pronouns
Please select
she, her, hers
he, him, his
they, them, theirs
Hill ID#
*
Class Year
*
Please select
2021
2022
2023
2024
2025
2026
Graduate Student
Phone Number
-
Area Code
Phone Number
Primary Injury/Illness/Impairment
*
Date of Injury/Illness/Impairment
*
-
Month
-
Day
Year
Date Picker Icon
Are you a student-athlete?
*
Yes
No
Did you sustain the injury while playing your sport?
Yes
No
Expected Length or Injury/Illness/Impairment
*
Briefly describe cause of impairment.
*
Describe your limitations and how they impact you at Stonehill.
*
List requested accommodations.
*
Where were you seen for medical treatment?
*
Health Services at Stonehill
Compass Medical
Primary Care Physician
Emergency Room/Hospital
Other
If available, upload documentation of your temporary impairment.
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