Disability Accommodation Request Form for Meal Plan
Dickinson College is deeply committed to the full participation of students with disabilities in all aspects of
College life, including dining experiences. In accordance with Section 504 of the Rehabilitation Act and the
Americans with Disabilities Act (ADA), Dickinson College has established procedures to ensure that students with
documented disabilities have access to reasonable on-campus meal plan accommodations. Students should
allow adequate time for application review and accommodation considerations.
All students living on campus are required to purchase a Dickinson College Meal Plan. This position is grounded
in principle. A major aspect of living at a residential college is table sharing and the opportunity for developing a
sense of community that arises in this setting. Occasionally students have special dietary needs and require an
accommodation to the Meal Plan in the form of a special diet. Many times these needs can be accommodated
by Dickinson College Dining Services. Exemptions from the Meal Plan are rare. They are made solely for
documented health conditions that require special medically necessitated diets that cannot be accommodated
by Dickinson Dining Services. In the rare instance Dining Services is unable to provide a reasonable dietary
accommodation, the student is granted an exemption and released from the Meal Plan.
For deadlines and information regarding the complete process for requesting disability-related Meal Plan
accommodations, please refer to the Disability Meal Plan Accommodations Procedures. Students must follow
these procedures and provide all the required information in order for a Meal Plan accommodation to be
considered.
If you have any questions about this process, please contact Marni Jones at jonesmar@dickinson.edu.
Name: _____________________________ Class Year: _________ Date: ________________
Email: _______________________@dickinson.edu Cell phone: _______________________
Do you already receive Disability Services accommodations? YES NO
If yes, please check all that apply: _____housing ____meal plan ____ academic
Please indicate if you are also requesting accommodations related to: ____ housing ___ academics
Current meal plan: __Traditional Plan __Flexboard I Plan __Flexboard II Plan __Apartment Flex Plan
Accommodation Requested for (check all that apply) ____Fall ___Spring ____Summer …of 20___
Is this request related to a temporary condition or impairment? YES NO
If yes, please indicate expected duration of need for accommodations:
What is your documented disability/medical condition?
Please provide an explanation with examples of how your disabling condition impacts your daily life.
Dickinson College Office of Disability Services Revised April, 2011
Explain how the accommodation(s) you are requesting will either fit into a treatment plan or serve to address
the functional limitations of your disability.
If your request is based on the need to avoid certain types of foods, what types of foods ARE you able to eat?
As a result of your disability or medical condition, what meal plan accommodation are you requesting to
mitigate these functional limitations?
____I have submitted a Disability Disclosure Form
(If unsure, please contact the Office of Disability Services)
Submit all forms to:
____I have read the Disability Meal Plan Accommodation/Exemption Procedures.
Marni Jones
____I have sent my relevant health care professional(s) the Office of Disability Services
Disability Meal Plan Documentation Form PO Box 1773, Biddle House
Dickinson College
____I have included documentation of my disability --OR-- Carlisle, PA 17013
____I have already submitted documentation of my disability --OR--
____You will be receiving documentation from my care provider Fax: (717) 245-1618
jonesmar@dickinson.edu
Please list below the health care professional(s) you are authorizing to provide us
with information about your disability and housing needs.
Name of Provider: Telephone #:
Name of Provider: Telephone #:
By my signature below, I give my consent for the Meal Plan Accommodation Committee to contact my
treating professional(s) for additional information as needed. Any such discussion will only focus on the
disability described on this form only, and how it relates to my requested accommodations.
________________________________ _______________
Student Signature Date
Note: If sending this form electronically, please type your name above and send this as an attachment using your Dickinson email account.
Dickinson College Office of Disability Services Revised April, 2011