Special Accessibility and Accommodations Request Form 1: Housing Accommodations

Special Accessibility and Accommodations Request Form 1: Housing Accommodations

Please complete this form and email the completed word document Bobbi Thomas, Dean of Academic Support sure to attach relevant documentation from a licensed health care provider, if appropriate. For all requests requiring medical documentation,Unity College utililzes a standard health care provider form available upon request and on the CLCSharePoint site. Students should forward this health care provider form to their respective health care provider. The respective health care provider should then return the completed form to Bobbi Thomas, Dean of Academic Support .

For additional instructions and background information, see the Accessibility and Accommodations General Information document on the CLC SharePoint site.

Note: This form will be forwarded to the Director of Residence Life/Assistant Dean of Student Affairs. The Director of Residence Life will then communicate with the student making the request to determine reasonable accommodations.

Questions should be addressed to:

Bobbi Thomas

Dean of Academic Support

207-509-7265

Steve Nason

Director of Residence Life/Assistant Dean for Student Affairs

207.509.7284

Student Information

Name:

Current address if living off campus or accepted, but not yet attending Unity College:

Telephone (Home):

Telephone (Mobile):

Semester Class Schedule (if known):

Course Name/Section Instructor Day/TimeLocation

Accommodations Requested for: ______Semester of ______Year

Today’s Date:

Please explain the reason for your special accommodation request and/or the nature of your disabilityif appropriate. How does this information impact your housing needs and your participation at Unity College?

Campus housing accommodations requested (please write “yes” in front of the accommodation you are requestingand briefly state the reason for any “yes” responses):

Accommodations:Explain why your particular needs require this specificaccommodation.

___Single Room

Please note: the standard rate for any student residing in a single room is $500.00 per semester above the double occupancy room rate. The single room rate is $3,299 per semester (subject to change).

___Private Bathroom

___Wheelchair accessible room

___First Floor

___Close Proximity to Classes

___Special Furniture

___Bed Board/Mattress

___Dietary (please be specific)

___Roommate

___Other (please be specific)

Electronic Submission Process

The student submitting this form agrees to the following:

Place an “X” if you agree to the stipulation described below:

______I submit this disclosure of my special housing need(s) and application for accommodations with the understanding that it is completely voluntary. I understand that by submitting this form and typing my name below, this information may be shared on a need to know basis with appropriate Unity College faculty and staff including but not limited tomy academic advisor, my instructors, and the staff of the CLC for use in understanding my needs and planning for appropriate support services.

Please type your name as an electronic signature and then send the completed word document to Bobbi Thomas, Dean of Academic Support .