Request for Modification to Housing and/or Dining Options (Student Information)

Name Name First Last
Student ID #
Date Date / MM / DD YYYY
Date of birth Date of birth / MM / DD YYYY
Sex

Sex Male Female
First semester enrolled at UNH
Current class status
Home address Home address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Local Address Local Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
What specific type of housing and/or dinging option do you require?
Explain how the above stated request to the condition that is the basis for your request.
What are the possible alternatives if the requested housing assignment and/or dining option are not possible?
The following section must be completed in order for your request to be reviewed by the Housing Modification Committee:

Authorization to Receive Confidential Information: I authorize members of the University of New Haven’s Housing Modification Committee to receive and review information from the professional/provider listed below, specific to this request for special housing and/or dining options. I also authorize my provider to discuss my condition(s) with the Director of the Accessibility Resources Center (or his/her designee) and/or the professional staff of the Health Services and/or the Counseling Center.
Name of Professional/Provider Name of Professional/Provider First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Request for Modification to Housing and/or Dining Options (Student Information)

Request for Modification to Housing and/or Dining Options (Student Information)

The following section must be completed in order for your request to be reviewed by the Housing Modification Committee: