Mary Baldwin College
OFFICE OF RESIDENCE LIFE
On Campus Housing Medical Exception Form
2015-2016
The Office of Residence Life seeks to provide special housing accommodations for students with
medical needs where possible. In order to request consideration for a health related exception, you
must submit this form along with a valid note by a health care provider. This form and the
accompanying documentation are due to the Office of Residence Life by 5 p.m. Monday,
April 6, 2015, in order to provide adequate time for processing prior to Housing Selection Process.
Requests received after the deadline may not be accommodated.
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Requests are reviewed on a case by case basis and evaluated in conjunction with the MBC
Health Center and Counseling and Psychological Services professionals.
Students must resubmit a Medical Exception Form and documentation from a health care
provider every year. Documentation submitted in previous years cannot be used. No
exceptions.
Students must pay the $300 deposit and clear their student account.
Students approved for special accommodations will be assigned prior to the Housing
Selection Process by the Office of Residence Life.
Room assignment is made based on meeting medical concerns first and foremost and
supersedes any preferences for building or roommate. Room assignments are made on a
first come first serve basis.
Students requesting accommodations can request a roommate of their choice provided that
the roommate meets eligibility requirements to live in a particular building and is cleared to
participate by the Office of Student Accounts.
If the medical need is for a single room, the student will be charged the single room fee of
$600/semester or $1,200/year.
Name __________________________________
Student ID Number_______________
Current Room Assignment _________________
Cell Phone ____________________
Current Academic Classification _____________
E-mail_________________________
Please describe the health condition prompting this request and what type of living environment
may help to alleviate symptoms of this condition.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Does this condition require treatment from a medical specialist? _____ Yes _____ No
If yes, please describe.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Health Care Provider Information
______________________________________________________________________
Name
_______________________________________________________________________
Title
_______________________________________________________________________
Address
_______________________________________________________________________
City State Zip
_______________________________________________________________________
Phone Number Fax Number
I am requesting special accommodations for the 2015-2016 academic year. I understand I must
pay the $300 advanced deposit and have a cleared student account in order to be assigned a
room in accordance with my request. I understand that if the request is approved, I will be assigned
a room that fits my particular needs (air-conditioned, single, etc.) and that those needs will take
precedent over all other requests (want a particular building, etc.). Additionally, I understand that I
must sign up for a room with the correct number of students for the room (double = two people,
triple = three people, etc.) or a roommate not of my choosing will be assigned. My roommate of
choice does not need to have a medical accommodation in order to be housed with me, however
she must pay the $300 deposit and have a cleared student account to be housed.
I pledge that the information contained on this form is accurate and true.
______________________________________________
Student Signature
________________
Date
Please return this form and documentation to the Office of Residence Life. For questions, please
contact 540-887-7221. Documentation can be faxed to 540-887-7227.