Personal Care Attendant Text Only Form

Personal Attendant Housing Request Form

I, ______________________________________ , have provided documentation that I require a personal attendant while I reside in University residence housing in order to accommodate my disability. The following is the necessary information regarding my personal attendant which is hereby provided and which I agree to provide to the University, when possible, prior to any change, and no later than within twenty-four (24) hours of any change:

Name of personal attendant:

Telephone number of personal attendant:

Company providing personal attendant, if applicable:

Address of company providing personal attendant, if applicable:

Street Address:
Suite / Office / Unit:
City: State: ZIP Code:

Telephone number for company providing attendant, if applicable:

I hereby certify that either I or the company with which I have contracted to provide me with a personal attendant, have carefully reviewed the personal attendant’s background information, including an adequate criminal background check and have determined that the attendant is not a possible risk to the safety of the students or employees of the University. I will promptly notify the University if the personal attendant is charged with any crime of violence, theft, or drug possession including any charge of assault or arson.

I realize that all personal attendants are expected to follow all applicable University policies, regulations, rules and procedures. If a personal attendant fails to abide by such policies, regulations, rules, and procedures and/or causes a fundamental alteration in services, programs, or activities, then the Office of Disability Services or Housing and Residence Life, or other University representative may make a determination that the personal attendant will not be allowed to accompany the student with a disability in the classroom, residence halls and/or other sites. If a personal attendant who resides in University housing fails to abide by the Contract for Residential Services signed by me and the policies, regulations, rules and procedures related to housing, Housing and Residence Life may make a determination that the personal attendant will not be allowed to live with me in University housing or have access to University housing. It is my responsibility to secure the services of another personal attendant in the event a personal attendant becomes unable to perform services for me or if the University makes a determination that the personal attendant is not allowed access to some or all of the University’s campus.

In the event of a dispute relating to the use of a personal attendant, I should follow the Student Grievance Procedures.

Signed: Date:

If the student is a minor, signature of student’s parent or appointed guardian:

Signed: Date:

Printed Name: