Pacific College of Oriental Medicine

Pacific College of Oriental Medicine Chicago Campus

Disabled Student Services- Declaration and Accommodations Request Form

Directions: if you are a student with a disability who would like to request accommodations please fill out this form, schedule an initial in-person appointment with a Disabled Student Support Services Officer (DSS Officer):

For all programs- Student Advisor Sarah Hawley 65 East Wacker Place, 21st Floor 773-477-4822 ext. 337 [email protected]

For all programs- Campus Director and Section 504 Coordinator, Teri Powers San Diego Campus 619-574-6909 ext. 142 [email protected]

Name______Phone #______

Local Address______

Email Address______(if other than your PCOM email)

Educational Program______Current Term ______

Please describe disabling condition and accommodations requested:

Disabling Condition______

Accommodations requested______

______

In order to receive accommodations, you may be required to provide verification of your disability, such as medical, psychological, and/or educational assessments of the impairment and current functional limitations. If you have verification, you may submit it with with this form at your initial meeting with a Disabled Student Services officer.

Please indicate the name, title, phone number, and office address of your verifying professional:

______

Student Signature______Date ______

7/11/16- egm