Public Accommodation Request

* indicates a required field

Please take some time to complete this form so that Ross University School of Medicine (RUSM) can best serve your needs. Note that the form must be completed in its entirety and documentation must be submitted before RUSM considers your request for accommodations.

Personal Information (to be completed by student)

Applicant
Enrolled
Please use your university issued email address
If no RUSM email address, please provide alternative email address

Impairment Information

The nature of my impairment is (check all that appy)






This impairment is (check only one):


I am applying for accommodations for (check all that apply):






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Certification and Documentation (Sections A, B, and C are to be completed by student)

Statement of Request

I, am providing clinical/medical documentation of my impairment. I hereby recognize that only original documentation completed/provided by certified or licensed professionals will be accepted to support my accommodation request

I, authorize to release my personal health information to RUSM. I further authorize RUSM to contact my healthcare provider for further information, and /or to use and disclose my information as necessary to consider my request for accommodation and to implement any approved accommodations.

Upload supporting document(s)