Intake For for Modified Housing

Today's Date Today's Date / MM / DD YYYY
Date Documentation Requested Date Documentation Requested / MM / DD YYYY
Year and semester entered UNH:
Name: Name: First Last
Student ID #
Date of birth: Date of birth: / MM / DD YYYY
Home Address: Home Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Current Residence Hall/Room:
Cell Phone Cell Phone - ### - ### ####
Gender:

Gender: Male Female
Race (optional):

Race (optional): White Hispanic Black Asian Native American Other Other
Class:

Class: Freshman Sophomore Junior Senior Graduate
Major Vocational Goal:
Disability:

Disability: Psychiatric/Emotional Chronic Health Related Hearing Visual Other Other
Please explain diagnosis in more detail:
Medications you are using as well as any known side effects:
Appliances you use (i.e. crutches):
Modifications you are requesting (e.g. wheelchair access, meal plan change:
Sources of Documentation of Disability:
Physician/Specialist:
Physician/Specialist Phone: Physician/Specialist Phone: - ### - ### ####
Agency/Clinic:
Agency/Clinic Phone: Agency/Clinic Phone: - ### - ### ####
Electronic Signature

By signing below, I am requesting reasonable accommodation for my disability/chronic health related condition. I also agree to adhere to the established policies and procedures for acquiring and maintaining such accommodations each semester that I am enrolled as a student
Draw your signature into the box below.

Draw or Type

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Full Name

I understand this is a legal representation of my signature.

Intake For for Modified Housing

Intake For for Modified Housing

Sources of Documentation of Disability:

Electronic Signature