To request a reasonable accommodation for a student’s housing ass - PDF document

To request assignment consideration for a disability, chronic health condition or other medical or personal issue(s), Department of Resident Life. The professional/provider must be thoroughly familiar with the student’s physical or assignment need. All information and documents provided to the Department of Resident Life will be kept con�dential. Any con�dential information will be shared only with relevant staff in a discreet manner and will be used only as permitted by law. This information will have no bearing on a student’s general eligibility for housing.Submission of the Assignment Consideration Form will be utilized by the University only with respect to the provision of on-campus housing. If you require academic/classroom accommodations you must register with Accessibility and https://www.counseling.umd.edu/ads/consideration and, as necessary, consult with Accessibility and Disability Service (ADS). If you are registered with ADS, you may arrange for ADS to release information on �le with ADS to Resident Life.The student must complete the top portion of the form below. The student, or their parent/legal guardian if under the age of eighteen (18), must �ll out and sign the Authorization to Release Healthcare Information below. This Student’s Name:ASSIGNMENT CONSIDERATION FORMSTUDENT FILLS OUT THE SECTION BELOW. PLEASE PRINT OR TYPE. 1102 Annapolis Hall Upload Online: Scan and upload via your Resident mydrl.umd.edu/Assignment Email: Scan and email to:drl-hsg-assignments@umd.edu page 1 of 4 Department of Resident Life for the sole purpose for assignment consideration to my housing because of a disability, Resident Life, if necessary.of a disability, chronic health condition, or other be submitted by May 31 (Fall Admission) or December 1 (Spring Admission) to be considered I have read and understand the information contained in this Assignment Consideration Form.AUTHORIZATION TO RELEASE INFORMATION: Address:City:State:Zip Code: page 2 of 4 To consider this student’s request for assignment consideration because of a disability, chronic health condition or of the student’s current medical condition from the treating licensed clinical professional or health care provider thoroughly familiar with this student’s condition and his/her functional limitations and/or restrictions. If the spaces provided are not adequate, please attach a separate sheet of paper.MEDICAL/HEALTH CARE PROVIDER COMPLETES AND SIGNS SECTION BELOW 1. Student’s disability/diagnosis: page 3 of 4 Does the student’s disability, chronic health condition or other medical or personal issue(s) signi�cantly limit any Name & Title: page 4 of 4