Special Housing Assignment Form, Academic Enrichment Center

The primary functions of a residence hall is to provide students with personal living space and a place to develop community. We aspire to assign all students to the most appropriate living space possible. Please assist us in our endeavor by submitting a completed form before May 25.

About You

Full Name *

Date of Birth *

MM-DD-YEAR (i.e., 02-15-1994)

Phone *

Email *

Street Address *

City

State

Zip

Country

Section A

Housing Questionnaire

My Housing Questionnaire has been submitted to Residence Life.

I require

a single room
an air conditioned residence hall
a first floor room
a quiet residence hall
a semi-private bathroom
room space for a service animal
the assistance of a personal attendant (Earlham does not provide personal attendants)
a room with accessible features (complete sections B - E)

Other

List of Major Life Activities Accommodated Through This Requirement

Section B

Minimum Height of Sink

Maximum Height of Sink

Desired Height of Toilet Paper Holder

I require

a roll-in shower
grabs bars in the toilet stall
a shower seat
assistance from attendant in the toilet stall

Section C

Common Areas in Residence Hall

I plan to do some cooking
I plan to use the washer and dryer

Section D: Residence Hall Room Furniture and Accessories — Standard furniture and accessories will be provided unless special instructions are noted below. Please be aware that it may take six weeks for the arrival of new furniture and equipment.

Minimum Height of Bed Mattress

Maximum Height of Bed Mattress

Minimum Height of Chest of Drawers

Maximum Height of Chest of Drawers

Minimum Height of Closet Rod and Shelves

Maximum Height of Closet Rod and Shelves

Other

I do not require a desk chair
I require a window lock installed at the lowest reasonable height
I require Venetian blinds
All control knobs/switches must meet the ADA guidelines

I prefer a

rockable-sled desk chair
four-legged desk chair

Section E: Additional Accessories for the Residence Hall Room — Please be aware that it may take six weeks for the arrival of new equipment.

Options

Visual door knocker
Automatic Door Opener
Strobe fire alarm
Braille signage
Extra space for disability related equipment
Extra power outlets for disability related equipment

An accessible phone with

an Amplified handset
TTY
Voice Carry Over/TTY

List equipment you will bring, including dimensions