Accessible Parking Request Form
Office of the Assistant to the President for Institutional Diversity and Equity
UNIVERSITY DISABILITY SERVICES
Employee Name *
Your answer
Affiliation/School *
Your answer
Department/Unit *
Your answer
Job Title
Your answer
Preferred telephone number *
Your answer
Preferred email address *
Your answer
Manager/Supervisor
Your answer
Human Resources Representative
Your answer
Work/housing address on campus (if applicable)
Your answer
Where do you currently park on campus? (if applicable)
Your answer
Where are you requesting to park?
Your answer
Are you requesting a temporary or permanent Harvard Parking permit?
For temporary passes, please indicate the start and end dates.
Your answer
Briefly describe your functional limitations *
Your answer
Do you have a state-issued disability parking permit?
If yes, what is the expiration date and placard number?
Your answer
Do you use a wheelchair or scooter?
Are you able to walk?
What is the maximum distance you can walk (in feet)?
Do you have difficulty negotiating stairs?
If yes, what is your maximum capacity of stairs? Please list the number of steps.
Your answer
Employee Signature
I understand that I am responsible for providing medical documentation from my health care provider(s) which substantiates my functional limitations and expected duration.
My typed name serves as my digital signature *
Your answer
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms