SPECIAL SCHEDULING NEEDS
Last Name:
Semester:
YOUR INFORMATION:
NEEDS INFORMATION:
First Name:
Medical Documents Attached:
Please submit this form to Human Resources by the specified deadline:
April 15
th
for the Fall semester and October 15
th
for the winter semester
If you have any medical condition requiring special arrangements for your schedule, attach all pertinent
medical documents or indicate when these will be forthcoming.
Yes
No
Email Address:
If not, what date will the documentation be forthcoming?:
Request: