Public Accommodation Request

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Student Information

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First Name

Last Name

Preferred Name

Pronouns

* Please use your Cal Poly email address (if available) for improved communication. * If you are not using a Cal Poly approved E-Mail address, be sure to check your 'junk/spam' folders for missing communication.

Personal Email

If you entered your Cal Poly email above, please enter a different, personal email address. If you entered a personal email address above, you can leave this question blank.

Primary Phone Number

Current Academic Level

Which term were you admitted to Cal Poly?

Affiliations/Identity

Specific Accommodation Information

Primary Disability Type

Additional Disabilities

Functional Limitations

Other Disability or Note

In what areas are you seeking DRC Services (check all that apply)

Are you seeking services for temporary or permanent disabilities?

Please describe the challenges or access needs that led you to request services?

List previous accommodations and/or resources you’ve received or used in the past (if applicable)

I am comfortable advocating for my disability-related needs

Voter registration Status

How did you hear about the DRC

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