Housing Accommodation Form - Taylor University

Request for Housing Accommodation
Academic Support Services
Student Name: __________________________________________________________________________
Social Security #: __________________________
Today’s Date: _____________________________
TU ID #: ___________________________________
Date of Request: ____________________________
My signature grants the release of the requested information to Taylor University.
Student Signature: ______________________________________________________________________
Do you have documentation on file in Academic Support Services? Yes
No
Purpose of this document— In accordance with Section 504 of the Rehabilitation Act of 1973 and the
Americans with Disability Act (ADA), individuals with disabilities are guaranteed certain protections and
rights of equal access to educational programs and services. Accommodations are made in relation to a
documented disability. Taylor University will collaborate with appropriate external agencies to provide
some accommodations.
The information requested on this form is to document a disability, determine the severity, and to help
determine reasonable accommodations for living on campus. To receive accommodations, students are
required to identify themselves to the office of Academic Support Services and to provide appropriate
documentation for their disability. The documentation must be dated within three (3) years of first request
to Taylor University and must include information that diagnoses the disability, indicates the severity and
longevity of the condition, and offers recommendations for necessary and appropriate residence adjustments.
Adequate Notification—Housing adjustments for disabilities depend upon reasonable notice of need. The
greater the adjustments needed in providing an accommodation, the greater the advance notice should be.
The ability of the University to respond to accommodations is directly related to the notification given by the
student. Taylor University Residence Life requires a twelve-week notice for physical modifications.
Please complete this form and/or attach a doctor’s statement/report if documentation is not currently
on file with Academic Support Services. The information will be protected as a confidential file with a
copy in Residence Life.
Please complete the following pages and return to:
Mr. Ken Taylor
Academic Support Services
Taylor University
236 West Reade Avenue
Upland, IN 46989
Voice: (765) 998-5523
Fax: (765) 998-5569
E-mail: kntaylor@taylor.edu

1. Diagnosis: __________________________________________________________________________
2. Date of diagnosis: _______________________ Date of last assessment: ________________________
3. If this is a temporary disability, date this verification will expire: _____________________________________
4. Clinical tools used to support diagnosis (I.E., x-rays, lab tests, physical findings, etc.): ______________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
5. Current prescriptions and/or treatment that may impact the student’s ability to live in campus housing:
___________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6. Functional limitations in a residential setting: ______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
7. What recommendations do you have regarding necessary and appropriate accommodations in a
residence environment? (Please provide a continuum of possibilities, if they exist.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Professional’s Signature: _________________________________ Date: _______________________
Printed Name and Title: _______________________________________________________________
Professional’s area of specialization: _____________________________________________________
Daytime Phone Number: ________________________________ Fax: ________________________
Address:____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________