Health Care Form - Providence College printable pdf download

Health Care Form - Providence College

Health Care Form for Students Requesting Special

Housing Accommodations

In order to evaluate how we can best meet your needs, we require specific information

from both you and your examiner. You must complete the top portion of the form below.

Also, to facilitate the process, we need you to fill out and sign the Authorization to

Receive Health Care Information below. This gives us permission to speak with your

examiner if we have questions relating to his/her recommendation for accommodation(s).

Your health care provider must complete the rest of this form, sign it, and return the

completed packet to the following address:

Providence College

1 Cunningham Square

Attention: Dr. Steven Sears

Office of the Dean of Students, Slavin 104

Providence, RI 02918

Student Fills Out This Page:

(Please Print or Type):

Student Name: __________________________________________________________

(Last)

(First)

(Middle)

Banner ID: ___________________________________________________

Birth Date: ________________________ Gender:

Male

Female

Class Year: _________________

Date of Request: __________________________

Home Address:

________________________________________________________________________

Home and Cell Phone Numbers:

________________________________________________________________________

Email Address: __________________________________________________________

Health Care Form - Providence College