Disability Resources - Residence Life Accommodations

Name:
UA Student ID #	Gender
Email:
Home Phone	Work or Cell Phone
Disability or Medial Condition (information should be pertinent to your request for a residence hall accommodation)
Is your disability documentation on file with UA Disability Resources?
Accommodation Request:
Wheelchair accessible room / accessible community bathroom
Wheelchair accessible room / accessible suite bathroom
Wheelchair accessible single / private accessible bathroom
Room equipped witha fire alarm strobe
Suite bathroom (usually shared by 4 persons)
Single room, community bathroom
Single room, suite bathroom
Single room, private bathroom
Extra refrigerator for medication / dietary requirements
Guaranteed roommate request
Other Explain:
List 5 residence hall preferences also submitted on your residence hall application:
1:
2:
3:
4:
5:
If you have a room mate request, please give: Room Mate Name Room Mate Student ID
Have you submitted your housing application to Residence Life?
Date application was submitted: