Meal Plan Accommodation Request Form

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Meal Plan Accommodation Request Form

Please submit your Meal Accommodation Request Form below. For additional information regarding on-campus services and general nutrition, please visit Dining Services’ website at https://basc1.org/eat/dietary-information/special-dietary-needs

Disability documentation to establish eligibility for a reasonable accommodation is required. Please submit supporting documentation to Hazen Center for Integrated Care Attn: Lynne Maier via fax at (585)-395-2559 or upload to the "My Hazen" student portal located at https://www.brockport.edu/life/health_center/

Documentation should meet all requirements outlined in section 3 of the Meal Plan Accommodation Process (https://basc1.org/eat/dietary-information/special-dietary-needs/20-eat-section/208-meal-plan-accommodation-request).

Student Name: Student Name: * First Last
Banner ID (800 Number) *
Brockport Email Address: *
Cell Phone: Cell Phone: * - ### - ### ####
Residence Hall: *
I'm a..... *
Have you previously been approved for a meal plan accommodation? *
Please provide detailed information about your disability and your dining accommodation needs. *
Are you currently being treated by a specialist for this condition? *
Do you follow a medically prescribed diet? *
What foods can you eat? *
Which foods must your avoid or limit? *
If approved, how will you adequately meet your dietary needs? *

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