APPLICATION FOR MEDICAL RESERVE PARKING

Comments

This field is for validation purposes and should be left unchanged.

Are you requesting a temporary or permanent Medical Reserve permit? *

Temporary
Permanent

Have you applied for Washington State-issued disabled parking privileges?

Yes
No

Date of Application

Applicant Information

Student I.D.# *

Date of Birth *

Name *

First Middle Last

Address *

Street Address City State ZIP Code

Phone Number *

Permission to leave a message? *

Yes
No

Alternate Phone Number

Permission to leave a message?

Yes
No

Email Address *

Vehicle Registration Information

Primary Vehicle:

License Plate # / State *

Year, Make and Model of Vehicle *

ex. 2008, Toyota Tacoma

Vehicle #2: (if applicable)

License Plate # / State

Year, Make and Model of Vehicle

Certify and Submit

SMS Disability Status *

I do hereby give permission to change my Disability status to Y on the registration screen in the Student Management System if I have not already done so on my course registration form.

Yes, change my disability status to "Y"
No, do not change my disability status to "Y"

Please be aware that the correct identification of your disability status in your student records is required in order to receive medical reserve parking privileges. Your status can be returned to "N" when you no longer have need of medical reserve parking.

By clicking "Submit", I agree to abide by the Medical Reserve Parking Rules and acknowledge that Grays Harbor College has the right to revoke my privileges at any time.