Housing Accommodations Form

Name*
First Last
Student ID*
Email Address*
Housing Accommodations Request*
- I am making this request based on disability-related NEED and believe my level of disability and documentation support this request.
- I am making this request as a PREFERENCE for a living situation that may work best for me based on my disability.
Note: If you choose option #1 above, registering with NIACC Disability Services and submitting documentation is necessary for consideration.
Provide a clear description of the desired housing configuration*
Explanation how the request relates to the impact of your disability*
Indicate the consequences if the accommodation is not provided*
List possible alternatives that may work if the housing accommodation request in not possible*
Digital Signature*
- By submitting this form, I verify the information I’m providing is accurate to the best of my knowledge and I will notify NIACC Disability Services of any changes that may arise.
Please send information about your disability that provides the basis of your request by a qualified provider to the following address.

North Iowa Area Community College
Attn: Lisa Vance
500 College Drive
Mason City, IA 50401