Medical Mobility Accommodation Application - Transportation and Parking

UNC PID:(Required)

Affiliation:(Required)

University Employee

Hospital Employee

Student

Residential Status(Required)

Resident (Living in UNC Housing)

Commuter (Off-Campus)

Name:(Required)

First Middle Last

Local Address:(Required)

Street Address City State ZIP Code

Email Address:(Required)

Enter Email Confirm Email

Work Phone:(Required)

Primary Phone Number:(Required)

Employee Details

Department Name:(Required)

Department Number:

Building Name/Work Location:(Required)

Work Schedule:(Required)

Student Details

On Campus Residence Location(Required)

Please describe the transportation access you need on-campus including buildings and locations:(Required)

Disability permits are assigned for one specific space and P2P is available for intra-campus travel to accommodate access to multiple locations.

Health Care Professional Information

Health Care Professional Statement(Required)

A completed Health Care Professional Statement must be included with the application submission. Students may contact Campus Health Services (919-966-2281) for assistance with the form.

Accepted file types: pdf, Max. file size: 20 MB.

CAPTCHA