Students requesting assistance through the Student Disability Resource Center for a temporarily disabling condition must complete this form. While all requests will be considered, there is no guarantee that such services will be provided.

Students requesting mobility assistance are encouraged to use the campus Trolley which meets federal requirements for accessibility.  Click here for the Trolley schedule (PDF).

Term Requesting Services Semester Fall Spring Summer Year 20 11 12 13 14 15

Last Name First Name MI Suffix Sr. Jr. II III IV

Local Address

Address

Apt/Suite/Rm/etc

City State ZIP Code

Phone Number Cell Phone Number

Your Official UWF Email Address (all correspondence will be sent to this account):

Confirm your Official UWF Email Address (all correspondence will be sent to this account):

What is the temporary disability?

What service(s) are you requesting?

Service Start Date

Service End Date

I certify that the information in this application is true and accurate to the best of my ability to answer the questions. I understand that this is an application for temporary support services and there is no guarantee that assistance will be provided.

SDRC will accept the electronic submission of this application as your signature.