<p> Pacific College of Oriental Medicine Chicago Campus</p><p>Disabled Student Services- Declaration and Accommodations Request Form </p><p>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): </p><p>For all programs- Student Advisor Sarah Hawley 65 East Wacker Place, 21st Floor 773-477-4822 ext. 337 [email protected]</p><p>For all programs- Campus Director and Section 504 Coordinator, Teri Powers San Diego Campus 619-574-6909 ext. 142 [email protected]</p><p>Name______Phone #______</p><p>Local Address______</p><p>Email Address______(if other than your PCOM email) </p><p>Educational Program______Current Term ______</p><p>Please describe disabling condition and accommodations requested: </p><p>Disabling Condition______</p><p>Accommodations requested______</p><p>______</p><p>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. </p><p>Please indicate the name, title, phone number, and office address of your verifying professional:</p><p>______</p><p>Student Signature______Date ______</p><p>7/11/16- egm</p>