Academic Support Center
Services for Students with Disabilities
1717 S. Chestnut Ave.
Fresno, CA 93702-4709
559-453-2247
wwwfresno.edu/disability-services
Application for Services / Accommodations
Student’s Name:
Date:
Mailing Address:
Student ID #:
City:
State:
Home Phone:
Cell phone:
Campus Cruiser E-mail:
Program: TUG, DC, GR
Zip Code:
@fpu.edu
DOB:
Campus: Main, North Fresno, Visalia, Bakersfield, Merced
Major:
Mentor or D.C. academic advisor:
In case of emergency, please notify
Name:
relationship:
Phone day/evening:
Describe your disability:
 Learning Disability
 Speech/language Impairment
 Mobility Impairment
 Psychological Disability
 Autism
 ADD/ADHD
 Other (please describe)




Hearing Impairment
Visual Impairment
Chronic Illness
Traumatic Brain Injury (including
concussion)
 Dietary
 I am requesting meal plan exemption/reduction only:
 Exemption
 Reduction
140 block 70 block
FRESNO PACIFIC MEAL PLAN POLICY: All students who live in freshman or sophomore housing at Fresno Pacific University are required
to be on a full access meal plan. Students placed in junior and senior housing may opt out of a meal plan if they choose. Exemptions
from the board plan are rare and only in the case of documented health conditions that require special diets which cannot be
accommodated by the food service provider. Financial difficulty does not qualify for an exemption or reduction. If you wish to apply for a
meal plan exemption or reduction you must be registered as a student with a disability prior to the second Friday of the semester for
which you are applying for an exemption. Requests submitted after that day will be considered for future terms. Requests for
exemptions must be submitted annually. Should an exemption or reduction be approved, Residence Life staff will make the financial
adjustment to your student account and with the food provider. Should the approval for your exemption or reduction happen after the
beginning of the semester you will be billed according to a 10 week refund schedule. Meal plan fees will be charged at 10% for each
week up to 10 weeks at which time there will be no refund. A week is defined as Sunday through Saturday
Student Signature
Date
By signing this form I verify that (1) all information provided on this form is correct and true; (2) I
have read, understand and agree to the information provided on procedures for applying for
accommodations and meal plan policies (if relevant to my request).
In order to ensure the provision of reasonable and appropriate accommodations, current
and complete documentation is required as is outlined on the back of this form.
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Procedure for requesting academic and non-academic accommodations:
Applicant’s responsibility:
1. In addition to this application, pick up the Verification of Disability, Confidentiality Waiver, and Rights
and Responsibilities forms and read thoroughly.
2. Fill out information requested completely.
3. Have your physician or other relevant health care professional complete the Verification of Disability
describing your need/disability. A business card or script must be attached. OR a letter in lieu of
this form must be on letterhead.
4. Submit the completed form to Services for Students with Disabilities
a. In person: via the Academic Support Center in Marpeck 105
b. By mail:
Melinda Gunning/Services for Students with Disabilities
1717 S. Chestnut Ave #13 / Fresno, CA 93702
c. By email: melinda.gunning@fresno.edu
5. Requests for housing assignment accommodations must be made prior to the beginning of the
semester and will only be granted as long as space permits.
6. Requests for meal-plan reductions must be submitted prior to the second Friday of the semester for
which you are applying for accommodations (Fall or Spring). Only fully completed forms will be
considered.
7. Requests for academic and other facility accommodations may be requested at any time during the
semester.
8. Requests for continuing accommodations must be renewed:
a. Academic (with or without non-academic) accommodations—every semester
b. Non-academic accommodations only—every academic year (August – May)
c. Updated verification may be required.
University responsibility:
1. The Academic Support Center director will review the request and supporting documentation.
2. If the accommodation(s) requested relate to housing and/or meal plan/dietary issues, the request will
be sent to the Assistant Dean for Student Development and Residence Life.
a. The Assistant Dean will meet with the food provider contracted by the university to
determine if a reasonable meal plan/diet or dietary accommodation can be made based on
the information provided by the physician. If no reasonable meal plan or meal plan
accommodation can be provided, the Assistant Dean and the Director of Food Services will
determine if an exemption or meal plan reduction is appropriate.
b. The Assistant Dean will contact you to communicate the final decision regarding your
request to be exempt or reduce your meal plan.
c. The Assistant Dean will make all necessary arrangements to adjust your student account.
d. See below for further meal plan policies.
3. For all other accommodations the ASC director or ASC assistant will talk with the student (in-person,
phone, or email) to negotiate appropriate accommodations.
4. A memo regarding academic accommodations will be sent to all faculty for the semester.
ADDITIONAL MEAL PLAN POLICIES:
 Exemptions for other reasons such as vegetarian diet, work or class schedule, access to a kitchen,
or personal preferences are not considered.
 Meal plan exemptions or reductions do not roll over from year to year.
 Requests are only considered when the application is complete and the documentation (in sufficient
detail) is provided.
 Medical documentation must be from a recognized expert (M.D. or Ph.D.)
 Meal plan exemption/reduction requests may be granted, denied, or the meal plan requirements
may be modified.
 Financial difficulty does not qualify for an exemption or reduction.
 If you don’t use all the meals assigned to you in a semester, meals do not roll over from semester to
semester which is not a reason for meal plan reduction.
Revised 2/13/2016 4:45 AM
116101237