Office of Residence Life and Housing

Request for Disability-Related Accommodations in Housing or Dining

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Name*

First

Last
WFU ID #*
Email
Current Class Status*
Phone
I have read and understand the Housing Selection Information on the Housing or Dining Accommodations website.*

CLICK TO VIEW THE HOUSING OR DINING ACCOMMODATIONS WEBSITE
- I agree.
Please answer the following questions thoroughly. Information provided will be reviewed by the Housing Accommodation Review Committee (HARC) in considering requests for reasonable accommodations.
Please specify your diagnosed disability for which a housing or dining accommodation is requested.*
Will the housing or dining accommodation be needed on a temporary or permanent basis? If temporary please include expected duration.*
Please specify the type of housing or dining accommodation you are requesting.*
Please provide a thorough explanation of how this request accommodates your disability for which you seek this accommodation.*

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Reasonable accommodations are considered on a case-by-case basis. Please check the box by each statement to indicate that you have read and understand the statements and agree to move forward with the process of requesting a reasonable housing or dining accommodation based upon your documented disability.
Documentation must be from a qualified health care provider who provides services to the student and who can describe how the student’s diagnosis impacts a major life activity as well as how the requested accommodation will address the functional limitations of their disability. The health care provider must be licensed and may not be a family friend or relative of the student. Statements or recommendations from the student’s physician should not be interpreted as automatic approval of a specific housing accommodation or room assignment.*
- I agree
The Housing Accommodation Review Committee (HARC) based upon the information provided by the student and a qualified healthcare provider. Members of the committee are staff of the Office of Residence Life and Housing, the Learning Assistance Center & Disability Services, the Student Health Service, and the campus dietician(s). Decisions made by the HARC are final.*
- I agree
Any student currently enrolled at the University who believes they have been discriminated against or harassed on the basis of disability by a Wake Forest employee or student may file a grievance with the University Section 504 Coordinator. The University has designated the following individual as the University’s Section 504 Coordinator: Tanya L Jachimiak, Director, Title IX Office, who may be contacted at jachimtl@nullwfu.edu or (336) 758-7258.*
- I agree
By submitting this form I have read and agree with the process. I have been truthful in my responses and understand that falsifying or misrepresenting facts or information may result in disciplinary action. Additionally, it gives permission to the Housing Accommodation Review Committee to review the documentation provided for the purpose of making an informed decision of my request.*
- I agree
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Request for Disability-Related Accommodations in Housing or Dining

Step 1 of 2

Office of Residence Life and Housing