Housing Accommodation Request

Your Information

Please note that the information on this form and any applicable documentation may be shared with the Academic Support Center Director and/or Assistant Director, as well as the Director of Counseling and/or College Nurse, as is appropriate. If you have questions about accommodations, please contact the Academic Support Center at 717-264-4141 ext. 3349 or via email at vickie.locke@wilson.edu.

Accomodation(s) Requested
Select as many as are applicable:

ANY INFORMATION PROVIDED ON THIS FORM IS STRICTLY CONFIDENTIAL

Information required with housing request

All accommodation requests must be supported by a detailed letter from your health care provider stating why a special housing accommodation is needed. Specifically, documentation MUST contain the following:

*Specific diagnosis and current treatment plan, if the latter is applicable.

*Description of necessary housing arrangements and possible alternatives if recommended accommodations are not available.

*Statement relating how the proposed housing arrangement will benefit the student and impact the diagnosed condition.

This letter must come from a specialist qualified to make this diagnosis; it may not come from a relative of the student; and it must be typed on letterhead and signed (no prescription pad notes will be accepted).

Please note that the information on this form and any applicable documentation may be shared with the Academic Support Center Director and/or Assistant Director, as well as the Director of Counseling and/or College Nurse, as is appropriate. If you have questions about accommodations, please contact the Academic Support Center at 717-264-4141 ext. 3349 or via email at vickie.locke@wilson.edu.