Request for Assistance with Temporary Medical Conditions Form

* First Name:
 
* Last Name:
 
* Student ID Number:
 
* BSC Email Address:
 
* Primary Phone Number:
 
* Services Requested:
Please note BSC is unable to provide personal transportation
 
Please submit additional supporting documentation which includes:
  1. A statement from the physician (on letterhead) which indicates the academic/physical limitation due to the temporary condition and the approximate length of time the student will be impacted by the limitation, as well as,
  2. A copy of the student's current class schedule
The above items can be delivered by any of the following methods:
  1. Drop off at the Office for Student Affairs, which is located in the Jack Science Center, Room 312
  2. Mail to Bismarck State College for Student Affairs, PO Box 5587, Bismarck, ND 58506-5587
  3. Fax to 701-224-2615
  4. E-mail to jay.meier@bismarckstate.edu
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