Stephen F. Austin State University

Residence Life Special Accommodation Request Form

Residence Life Department

The information requested below is for the purpose of providing reasonable accommodations for students with documented medical disabilities regarding campus housing. A person with a disability is defined as "any person who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment." While your request may be considered prior to you being accepted for admission to the university, actual accommodations and assignments will be provided following verification that you have been admitted and completed your residence hall application, deposit, and meningitis requirement.

Consideration for special accommodations includes the following steps:

Submit this Residence Life Special Accommodation Request Form to the Residence Life Department; and
Submit the appropriate medical documentation to Residence Life Department; and
Register with Disability Services (students are strongly encouraged to re-register with Disability Services each semester).

If necessary, Residence Life will consult with Disability Services and the Residence Life Accommodations Assessment Committee regarding your documentation and provision of reasonable accommodations. Please refer to the Guidelines for Documentation of a Disability, which outlines the procedure for requesting special accommodations. Your submission of this form gives permission for the Residence Life Department staff to discuss your disability with persons responsible for arranging appropriate reasonable accommodations and for committee review, if needed. Otherwise, information about your disability will be regarded as confidential.

Request Form

Fields marked with * are required.

Applying for Accommodation:*			Please select Hall preference
Fall Semester Spring Semester Summer Semester	Year:*		First choice: Griffith Hall 10 Hall14 Hall 16 Hall 20 Kerr Landing Lodge Steen East Steen West Village Wisely Off Campus	Second choice: Griffith Hall 10 Hall14 Hall 16 Hall 20 Kerr Landing Lodge Steen East Steen West Village Wisely Off Campus	Third choice: Griffith Hall 10 Hall14 Hall 16 Hall 20 Kerr Landing Lodge Steen East Steen West Village Wisely Off Campus
Name:*	Student ID#:*
Address:*	Student Cell Phone:*
City:*	State:*	Zip Code:*
SFA E-Mail address (all correspondence will be sent to this address):*

Please answer the following questions:

What is the nature of your disability?*

Indicate below a) the specific accommodations that you are requesting, and b) how the accommodation relates to your disability (e.g. first floor room due to mobility limitations). Refer to the criteria in the documentation guidelines (educational impact, severity, prescriptive treatments/medications, etc.).*

List any special equipment that you will bring which relates directly to your disability (e.g. wheelchair, specialized computer equipment, etc.).

List any special equipment that you are requesting from the Residence Life Department, which relates directly to your disability (e.g. emergency alarm flasher, etc.).

I plan to apply for academic accommodations. Please forward my physicians documentation to Disability Services.

Do you authorize a representative from the Residence Life Department to discuss your file with a parent or guardian? If so, please list the name(s).

Thank you for applying for special accommodations. We will process your file once you have submitted this form and appropriate medical documentation to the Residence Life Department. Please check your SFA email for correspondence regarding this request. Appropriate medical documentation must be forwarded to:

Residence Life Department
c/o Special Accommodations
Box 13054, SFA Station
Nacogdoches, TX 75962

936-468-2601
936-468-2074 (fax)

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