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: _________________________________________@student.fairfield.edu
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.