Housing Accommodations Request Form
Add release
Housing Accommodations Request Form
Part I. Completed by Student:
Student Name: _________________________________________Student ID: ______________
Phone Number: _________________________________ Date: _________________________
Current Address: ______________________________________________________________
_____________________________________________________________________________
Housing Accommodations Request: ________________________________________________
___________________________________________________________________________
_____________________________________________________________________________
Part II. Completed by Medical Provider:
In order for a student to apply for reasonable housing accommodations, students make a formal request using this form. A student who merits reasonable housing accommodations for disability-related issues submits this form, as well as accompanying documentation. This form is completed by the certifying professional of the student and the certifying professional also furnishes a copy of the documentation stipulated in the items below. The Reasonable Accommodations in Housing Review Committee will evaluate all of the information submitted for this request and will determine to what extent that the housing accommodations request will granted. The committee will inform the student in writing as to the final decision, with rationale for the decision.
Certifying Professional Name: _____________________________________________________
Title: _________________________________________________________________________
License Number: _______________________________________________________________
Office/Agency Name: ____________________________________________________________
Office/Agency Address: __________________________________________________________
Office/Agency Phone: ___________________________________________________________
Office/Agency Fax: _____________________________________________________________
Certifying Professional: Please answer the questions below and attach additional pages as necessary.
- Specific Disability/Diagnosis ___________________________________________________
2. How long has the student had this disability? ______________________________________
3. What is the severity of the disability? ____________________________________________
4. How long is the disability likely to persist? _______________________________________
5. Date of the diagnosis and last contact with student_________________________________
6. Describe the major life activities that are impaired and functional limitations that are substantially limited by the condition.
7. Please state specific recommendations regarding housing, and a rationale as to why these housing needs are warranted based on the student’s disability.
Medical Provider’s Signature: ___________________________________________________
Date: ______________________________________________________________________
Documentation will be kept in a confidential file available only to members of the Reasonable Accommodations in Housing Review Committee whose recommendations are based on whether the medical documentation meets the above guidelines. Students will receive notice of decisions in writing.
Please return to:
Kentucky, Memphis, & Tulsa Campuses:
Cindy Dean, Director of Student Success
204 N Lexington Ave, Wilmore, KY 40390
(859) 858-2393; FAX (859) 858-2021
Email: cindy.dean@asburyseminary.edu