Request for Assistance with Temporary Medical Conditions Form



* First Name: this field is required

* Last Name: this field is required

* Student ID Number: this field is required

* BSC Email Address: this field is required

* Primary Phone Number: this field is required

* Medical reason for applying (pregnancy, hospitalization, broken arm, etc.) this field is required

* Services Requested: Please note BSC is unable to provide personal transportation this field is required

Please submit additional supporting documentation. The documentation should: Be on letterhead and signed by the medical professional. Contain a clear diagnosis or explanation of what occurred. Identify the relevant limitations of the condition, such as "cannot walk for more than 30ft". State an approximate length of time the student will be impacted, if possible. The above items can be delivered by any of the following methods: Drop off at the Office for Student Accessibility Office located in Schafer Hall 135 Mail to Bismarck State College for Student Accessibility, PO Box 5587, Bismarck, ND 58506 Email to bsc.accessibility@bismarckstate.edu

Request for Assistance with Temporary Medical Conditions Form | Bismarck State College