SPECACCOM Application Form
Special Accommodation Request Application THIS FORM IS TO BE USED FOR HOUSING AND/OR PARKING ACCOMMODATION REQUESTS PLEASE FAX THIS COMPLETED FORM TO: Special Accommodations Committee at 203.254.5545 or deliver to Dolan Hall, Room 120 Personal Information: to be completed by the student requesting accommodation. Please print legibly, read, and sign the statement below. Last Name: ____________________________________________First Name:______________________ Fairfield ID #______________________________ _____________________________ E-mail Address: [email protected] Home Address: ____________________________________City:_____________State:_______ Campus Building, Rm #:_________________________________________________________________ Cell Phone: _________________________Home Phone: __________________________________ I am currently a: ____First-Year Student ____Transfer ____Sophomore ____Junior ____Senior Major:________________________________ 1) What are you applying for? (housing request, temporary parking pass, parking upgrade such as faculty parking, etc.) _____________________________________________________________________________________ 2) Parking/Housing request duration: from ____________________________ to __________________ 3) What is the reason for your request? Disability, extreme hardship, injury, employment (Stop & Shop lot only, other:________________________________________________________________________ 4) Have you applied for an accommodation in the past? If so, please explain_______________________ _____________________________________________________________________________________ Parking permits will not be granted for transportation to off-campus health or mental health appointments. Students are encouraged to use the University shuttle, obtain a ride from a junior or senior with a car, use a zip car, a bike or a cab. By signing and completing this form, I understand that I am requesting temporary privileges and further understand that my request will be reviewed by the Special Accommodations Committee. The review process may include contact my physical/mental health provider. I agree to comply with all related policies and procedures of Fairfield University housing/parking regulations. I understand that completing this form does not guarantee the request to be granted. I further certify that the above information is true and accurate. Students must re-apply each year for housing and each semester for parking accommodations. Signature: ____________________________________________________________________________ Today’s Date: _________________________________________________________________________ Certification of Applicant’s Disability To be completed by physician or the mental healthcare provider. Please print legibly, read, and sign the statement below. Use additional space on the back if needed. What is the physical or mental impairment (include history, first diagnosed), current problems and severity) and rationale for an accommodation? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ List any tests/evaluation measures used with the dates and results of the tests/evaluations. Please attach clinical data documenting the medical or psychological problem and the nature of the impairment. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe the treatment measures, including medication(s) and dosages that are currently being employed to treat this problem, or any assistive devices used. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What is the specific accommodation being requested and why? Are there alternatives? _____________________________________________________________________________________ _____________________________________________________________________________________ Physician or Mental Healthcare Provider’s Name (printed)/credentials: _____________________________________________________________________________________ Provider’s Office Address/phone number:__________________________________________________ _____________________________________________________________________________________ Signature and Date: ____________________________________________________________________ By signing this document, I authorize Fairfield University to contact me to obtain further patient information if needed. I further certify that the above information is valid and truthful to the best of my knowledge. Signature: ____________________________________________________________________________ For your own privacy we ask that you do not email this form. Please fax form to: (203) 254-5545 Attention: Special Accommodations Evaluation Committee Fairfield University 1073 North Benson Road Fairfield, CT 06824 or deliver to Dolan Hall, Room 120 Decisions and Appeals: Students will be advised in writing of the committee’s decision. A complete description of the appeals process is set forth in the Student Handbook and students are advised to consult that section before filing an appeal. Students may appeal this decision to the Dean of Students by submitting a copy of this document and a separate written letter of appeal. Students should note that appeals may only be based on 1) a showing that there was a substantial error in the process followed by the Special Accommodations Committee, or 2) new and relevant information not reasonable available to the student at the time of the Special Accommodations Committee’s decision has now become available. The Dean of Students will either respond to the appeal in writing or convene a Resolution Committee. Decisions will be entered within 15 days following completion of the investigation.
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