Click here to return to Messiah College's homepage
Office of Disability Services

Request for Medical Housing for Dietary Purposes

 

Please note that this form must be completed in addition to the Request for Special Housing.

 

In order to be eligible to be considered for special housing for dietary needs, follow these directions:

  1. print this form and complete the top section.
  2. Take the form for approval to the Director of Dining Services, Eisenhower 212A. The Director of Dining Services must be willing to sign that your request cannot be accommodated in the dining hall.
  3. Return the form to Disability Services (Hoffman 101) by Feb. 15.

 

Name and Student ID#: _________________________________________________

 

Dietary Needs:

 


Describe briefly the steps you have taken to arrange for your dietary needs (consultation w/campus nutritionist, meeting w/ Director of Dining Services, etc.):

 

 

Student Signature: _________________________________ Date: ____________________

********************************************************************
APPROVALS:

I affirm that the dietary needs of the above named student cannot be adequately met by the Dining Services Department. I recommend the student be approved for housing that accommodates the personal preparation of meals.

 

Approved by Dining Services: Signed: __________________________ Date:__________


Approved by Disability Services: Signed: __________________________ Date: _________