Fillable Student Housing Accommodation Request Form (State University of New York at Plattsburgh)

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Student Housing Accommodation Request Form (State University of New York at Plattsburgh)

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5/1/17
Student Housing Accommodation Request Form
Please complete this form in its entirety being as specific as possible. You should return this form with
the accompanying Medical/Psychological Documentation of Required Accommodation form if required.
Student Support Services will review all submitted materials and may make a determination based on the
material provided or may require additional information and/or verification. If determined necessary,
SSS will forward these materials to the Accommodative Housing Committee for a full committee review.
Student Name_________________________________________________________________
Student ID Number: 70__________ E-mail _________________________________________
Cell Phone Number ( _____) _________ Date of Birth ______________________________
Current Address _______________________________________________________________
This request is for accommodations to begin:
☐ Fall 20___ ☐ Spring 20___
Please briefly describe the disability for which you are requesting accommodative housing; how your condition
impacts your daily life; and how your condition affects you in a residential setting (e.g., residence halls):
5/1/17
Please indicate the specific housing accommodation(s) you are requesting (e.g., wheelchair accessible, visual
alarms, a single room, off-campus residence, etc):
Student Name Printed___________________________________________________________________
Student Signature____________________________________ Date submitted___________________
Submit Completed Application to:
Student Support Services
Angell Center 110
SUNY Plattsburgh
101 Broad Street
Plattsburgh, NY 12901
Fax - 518-564-2807
e-mail address to be set up
The disposition/outcome of your request will be provided to
you via e-mail to your SUNY Plattsburgh account.
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Student Housing Accommodation Request Form (State University of New York at Plattsburgh)

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Completed 27 August 2020

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