Seizure Disorder Emergency Accommodation Request Form

Student Information

Full Name Student ID Date of Birth Email Address Phone Number

---

Seizure Disorder Information

Diagnosis Physician Name Physician Contact Information Type of Seizures Known Triggers Seizure Frequency

---

Emergency Accommodation Requests

Requested Emergency Accommodations Preferred Emergency Response (if a seizure occurs) Medications (if any)

---

Emergency Contacts

Contact Name Relationship Phone Number Other Contact Information

---

Additional Information Signature Date