* indicates required value

First name *	*
Last name *	*
Cell phone number *	* * * * - * *
Email address you check regularly *	*
Are you a: *	MSM Student  MSM Staff  MSM Faculty  Other *
Is your disability temporary or permanent? *	Temporary  Permanent *
What is the nature of your disability? *	*
What kind of assistance are you requesting from first responders? (particularly as it relates to building evacuation)? *	*
MSM strongly recommends the use of a Rescue Assistant system, in which you designate a friend or colleague to help you in the event of an emergency. Do you have a Rescue Assistant? *	Yes  No *

* I understand that it is my responsibility to notify MSM of any changes to the above information – including contact information changes.





If you have any questions or concerns with this form, or if you have any updates to it, please reach out to Bryan Greaney, Director of Facilities and Campus Safety -- bgreaney@msmnyc.edu.