Medical Need Special Housing Request
You may request special housing if you have a qualified medical condition. Housing & Residence Life works in conjunction with Health Services and our on-campus medical professionals to ensure consistency in evaluating special housing requests. Only completed requests are reviewed. A completed request consists of this form, the
Information from Health Care Provider (Medical Request) form
, and the
Authorization for Disclosure of Health Information form
The medical provider must not have significant personal ties to the student or the student’s relatives beyond the professional relationship.
Requests and/or statements included in the medical documentation should not be interpreted as automatic approval for special housing
STUDENTS: February 17, 2014
STUDENTS FALL 2014: June 13, 2014
INFORMATION TO BE COMPLETED BY STUDENT:
Date of Request:
Furman Email Address:
Date of Birth:
Furman Student ID Number:
In the space below, please detail your request, to include the type of housing, and the reason(s) for it:
If medical documentation for this specific request is already on file with Furman University, please indicate the department that holds that documentation:.
NOTIFICATION OF APPROVAL/DENIAL WILL BE SENT TO THE STUDENT’S FURMAN UNIVERSITY E-MAIL ADDRESS. PLEASE MONITOR THAT E-MAIL FOR RESPONSE AND/OR REQUESTS FOR ADDITIONAL INFORMATION.
Do Not Fill This Out