COVID-19 Student Request for Support Form

COVID-19 Request for Support
We recognize the need for students with medical concerns on behalf of themselves or family members to seek additional support during this time of transition with campus COVID-19 masking policies. If appropriate, please use this form to submit your request for additional support as we transition to a mask-optional campus. If you have any questions about this form, please reach out to covidnurse@wheaton.edu
Student Name *

First Name Last Name
Student ID
Example: 55555
Phone Number

Area Code Phone Number
Email *
example@example.com
I am requesting additional support due to: *

My own health condition (physical or mental health) A family member's health condition
Area of campus where support is needed: *

Classroom Dining hall Housing Chapel Other
Please share the nature of your concern/request (you do not need to share personal medical information or documentation.) *
Describe the kind of support that you are seeking: *
While not necessary at this time, I understand that I may need to verify my request for support by providing a statement from a medical provider. I understand that, if this is needed, Student Health Services will inform me.
Signature

Clear
Date

Month Day Year
Should be Empty:

COVID-19 Request for Support