Center: View of Eastwood Residence Hall behind Christ the King Chapel; Right: Students eating in Residence Hall.
Special Needs Housing Request
Accommodations & Services
Policies & Procedures

Today's Date:
Name:
ID#:
Permanant Address:
  City:
State/Province:
ZIP/Postal Code:
Home Phone:
Local Address/
Campus Residence Hall:
City:
State/Province:
ZIP/Postal Code:
Local/Campus Phone:
e-mail:
Gender: [] Male
[] Female
Request for:   Year:
Class year: [] freshman
[] sophomore
[] junior
[] senior
[] graduate student
Housing Request: [] ground floor room
[] housing for an attendant
[] suite with private bath
  [] air-conditioned room
[] single room
[] apartment-style housing
[] wheelchair accessible room
[] Other...

 

Disability: [] Medical/Physical
Current Documentation must be submitted with each request [] Psychological/Cognitive
Diagnosis/Disability:

 

Please provide a brief description of the substantial limitation(s) that require special housing needs:

 

Please indicate modifications needed to be made to the housing accommodations to help eliminate barriers/limitations:

 

I permit that information regarding my disability be released to Residence Life.

[] Yes  [] No

All information is kept strictly confidential.  INITIATING THIS PROCESS DOES NOT GUARANTEE THE ACCOMMODATIONS WILL BE APPROVED.