Housing Accommodation Request Form

Housing Accommodation Request Form
Saint Mary-of-the-Woods College (SMWC) wishes to provide all of our students with an equal opportunity to use and enjoy campus housing. We recognize that a resident with a disability may need reasonable accommodations to equally enjoy campus housing as any other student. Completion of this request form will be reviewed for housing accomodations. However, housing placement will be based on availability of rooms. Each submission will be individually reviewed to evaluate the requested accommodation and how it will be implimented.

Please complete the form below if you are looking to request housing accommodations due to a diagnosis. All housing accommodations must be renewed annually.

If you have questions, please do not hesitate to reach out to LRC@smwc.edu.
Student Information
Date*

MonthDayYear
Date
Student Name *

First NameLast Name
Which of the following pronouns do you prefer to use?

They/ThemShe/HerHe/HimZe/HirNo PreferenceNone (just use my name only)Other
Student ID Number
Date of Birth *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
SMWC Email*
example@smwc.edu
Accommodation Request
Current Request Term *
Please provide us with your diagnosis or disability. *
Which housing accommodations are you requesting?*

Emotional Support AnimalRoom Near ElevatorRoom Near StairwellHandicap Accessible RoomSingle RoomSingle BathroomAllergen-Friendly RoommatesVisual Alarms for Deaf/Hard of HearingService AnimalOther
Do you need to speak with an ADA advisor at Saint Mary-of-the-Woods College about your options?

YesNo
In the space provided, please explain (in as much detail as possible) why you believe you need the above-requested housing accommodation(s) and how it will help you better enjoy your residential space: *
If an emergency arises in your building, will you need assistance exiting the building?If you answer "yes," you will be added to the Emergency Evacuation List. *
Provider Information
In order to properly evaluate how Saint Mary-of-the-Woods college can best meet your need for reasonable accommodations in college owned and operated housing facilities, the college requires specific diagnostic information from a licensed professional, such as a therapist, pscychologist, psychatrist, or primary care physician. The provider should be a regular provider for your treatment and must be familiar with the history and functional limitations of your physical or psychological condition(s).
Provider Name*

First NameLast Name
Provider Title/Certification (Medical Doctor, Licensed Clinical Social Worker, Therapist, etc.)*
Provider Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Phone Number *
Please enter a valid phone number.
Provider Email (Optional)
example@example.com
Fax Number (recommended)
Please enter a valid fax number.
Length of Time Under Care (2 years, etc...)*
Date of Most Recent Evaluation/Consultation*
Additional Providers?

If you have an additional healthcare provider or other licensed medical professional that is important to your treatment goals, please list them here.
Do you need to add an additional healthcare provider or another licensed professional providing care in your treatment?

YesNo
Provider Name*

First NameLast Name
Provider Title/Certification (Medical Doctor, Licensed Clinical Social Worker, Therapist, etc.)*
Provider Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Phone Number *
Please enter a valid phone number.
Provider Email (Optional)
example@example.com
Fax Number (recommended)
Please enter a valid fax number.
Length of Time Under Care (2 years, etc...)*
Date of Most Recent Evaluation/Consultation*
Confidentiality

By signing below, I authorize Saint Mary-of-the-Woods College Residential Life and Disability Support Services to receive documentation and information relevant to my request for a housing accommodation from my provider whom I have listed above. I also authorize my provider to discuss my condition(s) and the documentation and information provided with the appropriate SMWC personnel on an as-needed basis. I understand this information will be kept strictly confidential, except when permission to disclose information is granted by student; however, Disability Support Services staff are required to disclose information when an individual presents a danger to self or others, when subpoenaed for records or testimony in court, or due to a need-to-know basis by university officials.
I,First Name* Last Name* , agree to complete additional documentation and requirements with Campus Life before bringing their animal to reside on campus. A separate email will be sent to inform you of the documentation and training required.
I, First Name* Last Name*, have read and understand that completing this request form does not automatically qualify me for a housing accommodation. Additional documentation to support a housing accommodation request may be required. I understand that each request must be reviewed individually to ensure that each student is given a fair and reasonable accommodation given their situation. If placed into a housing accommodation, it is my responsibility to cover the cost of the housing assignment if a change is cost is applicable.
Student Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

Housing Accommodation Request Form

Student Information

Accommodation Request

Provider Information

Additional Providers?

Confidentiality