Request for Accomodations for International Study Program

* indicates required field.

Contact Information:

Name:

* NEU Email:

Local Address:

City:

State:

Zip:

Phone:

V TTY Pager

Major:

Registration Information:

Are you registered with the DRC?

Yes No

If yes, who is your DRC Specialist?

If no, please answer the following thoroughly:

Do you have a disability/medical condition for which you are requesting special accommodations? If so, please describe in detail your disability/medical condition, specify the accommodation you seek, and the reason you are requesting that accommodation.
Please complete the following areas:
Host School Name:

Host School Address:

Host School Contact Person:

Date of Departure: