ࡱ> -/,} 0 bjbjΨ .ʤfʤfhh*t>(ffffAAA@BBBBBB$5vfAAfff{ ff@@fN ,0a"aaA0q"AAAffAAAaAAAAAAAAAhX :  YESHIVA UNIVERSITY Office of Disability Services Beren Campus Wilf Campus Dr. Rochelle Kohn Ms. Abby Kelsen  HYPERLINK "mailto:Rkohn1@yu.edu" Rkohn1@yu.edu  HYPERLINK "mailto:akelsen@yu.edu" akelsen@yu.edu 646-592-4132 646-592-4280 Fax: 917-326-4811 REQUEST FOR MEAL PLAN MODIFICATION Name: ID: I am requesting exemption from the meal plan at 鶹ýӳ due to a medical condition. Nature of Condition: I understand that my request is not complete without a letter from my physician documenting my condition and supporting my request. I hereby grant permission to the designated physician affiliated with 鶹ýӳ and/or Yeshiva personnel to obtain and/or release information regarding my exemption request to and/or from the person and/or facility below: Physicians name: Phone: ______________________________ ___________________ Student Signature Date 12>CDOPwx       7 C D E F J K L N P Q S T U V 礚yuhq&hh1,C5>*\h}zhk1h-hh-5\hhq&5\hhq&5>*\hS5CJaJhcpI5CJaJhq&5CJaJhRuhq&5h; h1BhRu0JjhRuUhRu hBvhBv hRu5hBvhBv5,12Pw   D E F V W X W X @ gd/'gdq&gdcpI$a$gdq&gdRu$a$gdcpIV W X  V W X y  ! . > ? @ A B C K O R S T X ĽwmchhMv5\hh-5\hhq&5\hhq&5>*\hh/'5>*\hhcpI5>*\ h6hQEhq&h hQEh^sh-2 hBvh h6hq& h6hcpIh/'hhh; 5\hh; 5>*\ h>*h; hRuhcpI&@ A B a b c d e f g gd &d P gd$<&d P `gdBv &d P gd-2gd/'gdq& X ] _ ` a b c d e f g  ÿÿÿ÷hq&CJaJhy h6h6h hnTh-2hh+5\hhMv5\hh/'5\hh/'5>*\,1h/ =!"#$% x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_H