Personal Information

Full Name

Student ID

Student Phone Number

UM Email

Personal Email

I am a (Check one):

Current student requesting accommodations for the future academic year.

New student applying for accommodations to begin my first semester.

Student returning from leave or other time away; requesting accommodations for my first semester back.

Current student requesting accommodations for my current housing placement.

Start term (first term to which this accommodation would apply):

Are you a transfer student?

Current On-campus Housing Assignment (If applicable):

Accommodation Information

Have you previously applied for disability-related housing accommodations at University of Mobile?

If yes, in the space below please briefly list any housing-based accommodations that you received in the past and describe whether they were satisfactory or not.
Please note: we cannot guarantee you will be placed in the same location as the previous year, but you can specify that here as a preference.

Housing accommodations currently being requested: Please be as specific about your needs as possible.

Disability Information

Documented disability/disabilities:

In the space below, please provide a personal statement describing your condition and your need for each of the accommodations you are requesting. (You may also attach a separate document with this information, if you choose.)
Supporting Documentation: Please submit supporting documentation in accordance with our documentation guidelines, which can be found on MyUM under Student Success: Welcome Guide for Students with Disabilities
If documentation is already on file, you do not need to re-submit. Accommodations requests without appropriate supporting documentation will not be reviewed until such documentation is provided.

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Disclosure Agreement

I allow this information, including medical documentation, to be reviewed by the Housing Accommodation Committee in order to make a determination regarding my request to be considered for an on-campus housing accommodation.

Your file will only be reviewed by University of Mobile administrators in offices relevant to your case. These offices may include the Disability Support Services Office, Residential Life Office, Health and Counseling Services and Dining Services if applicable.

The Housing Accommodation Committee will consider your requests and utilize these materials to determine the most appropriate placement and/or accommodation for you.
Once a determination of eligibility placement and/or accommodation is made, you will be notified of your accommodations by the Disability Support Services Office. The Residential Life Office will notify you of your specific placement or relevant administrative information for your accommodations.
Students who decline their placement and choose to go through the general room selection process will not be able to retain the original accommodated assignment once declined.
Submission of the Housing Accommodation Request Form, with or without supporting medical documentation, does not guarantee that you will receive the requested accommodation. University of Mobile reserves the right to propose alternative reasonable accommodations based on an individual assessment of your case.

Name (*Typing your full name will serve as your signature authorization)

By signing above, I am indicating that I have presented this information accurately and to the best of my knowledge. I allow this information, including medical documentation, to be reviewed by the Disability Support Services Office and the Residential Life Office in order to make a determination regarding my request for an on-campus housing accommodation.