Office of Accessibility and Accommodations

Medical Release Request

Note: Appropriate documentation is required, and release request will not be considered without it. All supporting materials must be attached and submitted with this form.

Name(Required)

First Last

MUID(Required)

Date of Birth(Required)

Building and Room #(Required)

Cell Phone(Required)

Email(Required)

Name of Parent or Legal Guardian(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Telephone Number(Required)

Reason for Medical Release Request

Date(Required)

Medical Release Request

Reason for Medical Release Request

Disability Services