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louisville.edu
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Housing Accommodation Request Form
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Housing Accommodation Request Form
Housing Accommodation Request Form
Please submit this form to request disability-related accommodations in University Housing.
Student First Name (preferred)
Student Last Name
Student Legal Name (if different from preferred)
Pronouns
he/him/his
she/her/hers
they/them/their
Student ID#
E-Mail Address
Phone Number
Current Hall Assignment (if assigned)
When will you first need this accommodation?
Spring 2025 - Priority deadline has passed. Accommodations may not be finalized until the following semester.
Summer 2025
Fall 2025
Accommodation(s) Requested
Please check all that apply.
Wheelchair accessible residence
Visual alarms for the deaf/hard of hearing
Non-shared bedroom
Immediate proximity to shared bathroom
Adjoining bathroom (shared)
Adjoining bathroom (shared with only one roommate)
Dietitian referral to assess kitchen access needs
First-floor room assignment
Allergen-friendly roommate(s)
Emotional Support Animal
Other
If other, please indicate what accommodation is needed.
If requesting an Emotional Support Animal, please indicate the type and age of the animal.
Describe how the accommodation(s) would impact your ability to fully participate in the University Housing program.
Documentation
Attach supporting documentation from your health provider.
If an emergency arises in your building, will you need assistance exiting the building?
If yes, you will be added to the Emergency Evacuation List.
Yes
No
I understand that the Disability Resource Center may communicate with University Housing about my accommodation request.
Signature
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