Student Name ID#

Semester: Spring Fall Summer I Summer II Phone Number Alt. Phone Number

E-Mail

Please list the day and time for each Room# where access furniture will be needed:

Room # Day Time

Room # Day Time

Room # Day Time

Room # Day Time

Room # Day Time

Please indicate the reason for requesting access furniture

Large Size Seating
Disability or Injury
Other: Please Explain:

If this furniture request is due to the presence of a disability or an injury, documentation must be presented to Disability Services for review in room C237.

Documentation of disability or injury had been presented to the Disability Services Office.
Yes No

Note: If padded chairs are needed due to a disability or injury, ergonomically engineered chair pads can be checked out through the Disability Services office (C237). Documentation of a disability or injury is required for this service.

Please indicate the Access Furniture needed

Table and Chair
Wheelchair access table
Other: Please Describe

Additional Comments