University of Kentucky Housing Application for Students Requesting Accommodations
Patient's Name: ___________________
Each student in University housing is required to sign I housing agreement/contract
for the full academic year (fall and spring semesters). The agreement
is strictly adhered to with exceptions made only under special circumstances
in case of necessity.
A "medical necessity" would include those conditions for which
the prescribed treatment is tot) unique to reasonably follow or accommodate
while living. in a residence ball or other campus housing. The completion
(if this form does not constitute an automatic contract release nor should
acceptance of this form by the University be construed as a commitment
to release.
This form is to be completed by a licensed physician. Please respond
to all questions asked. This information will be reviewed by the
Office of the Dean of Students in consultation with the University Health
Service.
Specific diagnosis or nature of medical condition: Date illness was diagnosed: Type of treatment prescribed: Date of last contact regarding the medical condition: In what specific way does living in the residence hall/undergraduate
apartments contribute it) or exacerbate this medical condition? Include or attach information on test results, surgeries, medication,
special diets or other information that supports this request. Does the patient require environmental control, such as filtration
system. air conditioning. carpet free space. etc.? Specify. Other information in support of this request for a housing contract
release:
Physician's Name Physician's Address Date phone Physician's Signature
Return to:
Dean of Students Office
University of Kentucky
513 Patterson Office Towel,
Lexington. Kentuckv 40506-0027
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