Commencement Accessibility Request Form

Please complete the form by May 16, 2022 for each individual requesting accessibility related services.

Name of Student Graduating*

First Last

Name of person requiring accommodation*

First Last

Indicate your position as an attendee*

Name of Person to contact regarding this accommodation

Contact Name*

First Last

Email*

Day Phone*

Evening Phone

Nature of Accessibility Need (check all that apply)*

Other, please explain:

Request for Accommodations (check all that apply)*

Accessible Reserved Seating, # of seats requested:

Indicate mobility devices that you will be bringing with you (check all that apply)

Other mobility devices, please describe:

For those needing to rent medical equipment such as wheelchairs, a local vendor is available: County Square Pharmacy 508-222-7620

Please provide any other information that will be helpful in accommodating your needs:

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