Public Accommodation Request

* indicates a required field

Student Information

Please enter your information

First Name *

Last Name *

Middle Name

WIN (Western Identification Number) *

Birthday *

WMU Email *

Please use your university issued email address

Cell Phone Number *

Military Status

Are you active military or a veteran?

Service Agencies

Are you a client or receiving services from any State or Federal Agency?

Disability Information

Instructions: There is much variability within each disability category, and therefore, the type of accommodations needed can vary significantly. Below, you will find descriptions of the various types of disabilities recognized in the United States. Student needs vary according to each individual. Therefore, it is important for the participating student to clarify the particular disability.

My diagnosed disability falls into the following category *

You may select as many disabilities with which you identify

Do you use assistive technology? *

How does your disability affect you academically? *

What accommodations are you requesting? *

Accommodation

Have you received accommodations in the past? *

Upload supporting document(s)

If you have documentation, such as IEP, 504 plan, medical information, psychological evaluation or other information concerning you disability, please upload it now.