Special Dining Services Request

Questions regarding completing this form maybe directed to:
specialdiningcommittee@muhlenberg.edu

Full Name*

First NameLast Name

Phone Number*

Are you a current student?*

YesNo

Class Year

Residence Hall

Current Meal Plan

Email Address*

If you're a current student, please use your Muhlenberg Email address.

Special Dining Services Request:*

Briefly describe how your medical condition warrants the accommodations requested (including medical diagnosis, date of onset, and symptoms):*

Do you feel your medical condition will impact your residential services needs and/or assignment?*

YesNo

Please visit the Special Housing Requests webpage to complete a housing application along with your Special Dining Services request.

Did your health care professional recommend a specific diet due to your medical condition?*

YesNo

Please list recommended diet and the reason for the recommendation

Tell us about your dietary history:

What specific foods do you eat due to your condition?*

What specific foods do you NOT eat due to your condition and why?*

Have you had any unintentional weight gain or loss in the last 6 months?*

YesNo

Please explain:

Are you responsible for any of your own food preparation? Please describe:

I understand that I must complete the Special Dining Services Request Application and provide supporting documentation to the Office of Disability Services in order to be considered for this request. The completed application includes a Report of Evaluation and statement of medical necessity from the appropriate diagnostician to support my request.*

I Understand

Signature*

Date*

All Special Dining Committee decisions will be sent to student’s Muhlenberg email from: specialdiningcommittee@muhlenberg.edu

Submission of application and documentation may be directed to: Special Dining Committee, Office of Disability Services Phone: 484-664-3825; Fax: 484-664-3697 or specialdiningcommittee@muhlenberg.edu

All Muhlenberg College students have the right to file a grievance if they believe they have been subjected to discrimination on the basis of a disability, have been denied access, or have been denied a reasonable accommodation under the Americans with Disabilities Act. Questions or concerns about these issues may be directed to: Dean of Students and/or Director of Equity and Title IX Phone: 484-664-3562