Petition for Reasonable Housing Accommodation Assignment

In order to qualify for consideration for submitting this Petition for Reasonable Housing Accommodation Assignment (PRHAA) form, students must have already submitted the Student Access Registration with supporting documentation. If you have not done that, please do so HERE. If you have already done so, kindly respond below.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone(Required)

Email(Required)

Student ID(Required)

Student Status(Required)

New Incoming Student

Current Student

Transfer Student

Please indicate your disability type(s)

(At least one of the disabilities must be selected below)

NEURODEVELOPMENTAL DISABILITY

ADHD

Autism Spectrum Disorder

Communications/Speech

Learning Disability

Motor

SENSORY DISABILITY

Blind

Low Vision

Deaf

Hard of Hearing

MENTAL HEALTH

Mental Health

PHYSICAL DISABILITY

Basic Chronic Medical Condition

Mobility

Orthopedic

INTERSYSTEM DISABILITY

Alcohol/Substance Abuse Recovery

Complex Chronic Medical Condition

Traumatic Brain Injury

TEMPORARY DISABILITIES

Temporary Disabilities

MULTIPLE DISABILITIES

Multiple Disabilities

PLEASE INDICATE BELOW THE HOUSING ACCOMMODATION ASSIGNMENT YOU ARE REQUESTING: (MUST SELECT AT LEAST ONE OF THE FOLLOWING)(Required)

Single residence hall room

Accessible room/facilities (including ramp, elevator, and/or 1st floor room)

ESA (Emotional Support Animal)

Other (please describe)

OTHER(Required)

Emotional Support Animal Information

Emotional Support Animal (ESA) Agreement

An ESA provides emotional support that alleviates one or more identified symptoms or effects of a person’s disability. Five Towns College (FTC) is committed to reasonably accommodating individuals with disabilities. With respect to each request for an ESA, FTC will determine, on a case-by-case basis, and in accordance with applicable laws and regulations, whether the animal constitutes a reasonable accommodation.

Requests for an ESA involve completing the Emotional Support Animal Application Packet along with the initial Petition for Reasonable Housing Accommodation. To ensure that you will receive a decision regarding the application before the start of the academic year, please submit all documentation by July 15th for the fall semester and December 1st for the spring semester.

ESAs will not be permitted if they pose a direct threat to the health or safety of others, would cause substantial physical damage to the property of others, pose an undue financial or administrative burden, or fundamentally alter the nature of the educational operations of Five Towns College.

All students requesting the use of an ESA must complete this form, submit the required documentation, and receive approval from the Offices of Residential Life and Student Access.

Animal Name(Required)

Animal Type(Required)

Animal Breed(Required)

Hair/Fur Length(Required)

Animal Size & Weight(Required)

Crate / Tank Dimensions(Required)

Local Veterinarian Name(Required)

Local Veterinarian Phone(Required)

Local Veterinarian Address(Required)

TREATING PROFESSIONAL FORM REQUEST FOR ESA(Required)

Completed and signed. CLICK HERE to download the template.

Drop files here or

Max. file size: 50 MB.

Veterinarian Form(Required)

Completed and signed. CLICK HERE to download the template.

Drop files here or

Max. file size: 50 MB.

Please read the following carefully and consent:

Animal Care:

In the case of a hospitalization/emergency, I give Student Access Office and The Office of Residence Life permission to contact the below emergency contact (who should be able to commute to campus in reasonably short period of time) and have them come to pick up my animal and take care of it until I am able to return to my residence hall (This must be a family member/individual who resides off campus as the animal is not permitted to remain in a residence hall without the owner.)

Emergency Contact Person:(Required)

Relationship:(Required)

Phone Number:(Required)

Emergency Contact Person #2:

Relationship:

Phone Number:

ESA Interaction and Behavior:

BRIEFLY DESCRIBE WHY YOU ARE REQUESTING THE ABOVE ACCOMMODATIONS:(Required)

Section 504 & ADA allow colleges to require documentation of a disability in order to determine the most appropriate accommodations that a student will need. The SAO holds all documentation in the strictest confidence and will not release specific information without authorization from the student. Guidelines for documentation are available upon request.

PLEASE CHECK ONE OF THE FOLLOWING(Required)

I am using documentation already in my file with the Student Access Office

I am submitting new or additional documentation

PLEASE ATTACH ALL DOCUMENTATION TO YOUR PETITION REQUEST FORM.(Required)

Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.

*Only accept PDF file type.

By submitting this Petition, the individual named below hereby acknowledges, understands and agrees that he/she/they have read the institution's Emotional Support Policy included in the Five Towns College Residence Life Handbook at pages 13-20, the same being fully incorporated by reference here, and will adhere to same.(Required)

FULL NAME

By submitting this Petition, the individual named below hereby acknowledges, understands and agrees that he/she/they have read the Five Towns College Residence Life Handbook, the same being fully incorporated by reference here, and will adhere to same.(Required)

FULL NAME

Please allow a reasonable time-frame for Student Access Office to review each petition and documentation provided.

Student Access Office:

Email: student.access@ftc.edu | Phone: 631-656-3131 | Fax: 631-656-3154 | Office Location: Room 106A