viterbologo Exception from a
            Meal Plan as a Reasonable Accommodation
          
 
This form is to be completed by the professional who evaluated this student.

Please complete this form to provide needed medical information (diagnosis) for this student:
Student Full Name:  
 
Please provide required information: name and credentials of the professional providing this information.
Professional's Name:         
Professional Credentials:     
Professional Phone:     
 
The information below will help determine:
  • Whether this student meets criteria for an individual with a disability according to federal law
  • Appropriate and reasonable accommodations that are supportive of this request
 
1.   Clear statement(s) of the condition(s) including diagnosis, date of diagnosis and expected duration of the diagnosed condition.
 
2.   The basis for the diagnosis including testing and date of onset of this condition.
 
3.   The functional limitations that result from this diagnosis.
 
4.   What is the severity of the impact of the condition/diagnosis on the student's performance of major life activities in comparison to most people in the general population?
 
5.   Recommended accommodation(s). The student is requesting exemption from the meal plan based on a medical diagnosis. If you believe that exemption from the meal plan is necessary and vital for the student’s health, please explain. NOTE: Students sign a contract to participate in a meal plan when living on campus. Dining hall personnel will work with students to meet diagnosed dietary needs.
 
We may request additional or more detailed information.
 
My signature below affirms that the information I am providing is true and correct. 
ESignature:  
 
***Please print and retain a copy for your records if needed.  
 
Thank you.,
Jane Eddy  
Director, Academic Resource Center  
Coordinator of Disability Services  
Viterbo University  
608-796-3194 | jleddy@viterbo.edu  
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