Fillable Disabilities Disclosure and Request for Accommodation If you (Pfeiffer University)

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Disabilities Disclosure and Request for Accommodation If you (Pfeiffer University)

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Disabilities Disclosure and Request for Accommodation
If you have a documented disability (a learning disability, ADD, ADHD, mobility problems, health
concerns, significant hearing or vision problems) that will require accommodation, please
complete this form and provide documentation from an appropriate licensed or certified
professional. The requirements for the documentation can be obtained from the Learning
Center.
Misenheimer students:
Dr. J
im Gulledge
Director of Academic Support Services/504 Officer
Pfeiffer University
P.O. Box 960
Misenheimer, North Carolina 28109
(704) 463-3366
jim.gulledge@pfeiffer.edu
Charlotte and RTP students:
Dr. Joanne Zukowski
Director of Graduate/Adult Development and Student Success
Pfeiffer University-Charlotte
4701 Park Road
Charlotte, North Carolina 28209
(704) 945-7309
joanne.zukowski@pfeiffer.edu
First Name
Last Name
Phone Number
Email Address
ALL INFORMATION ABOUT YOUR DISABILITY WILL BE TREATED CONFIDENTIALLY
What is your disability? (Be specific: health, dyslexia, etc.)
How does this disability affect your class work, class schedule or class location?
What accommodations are required?
Please note that all appropriate documentation must be submitted before accommodations
can be implemented. We request that you give permission for the Disabilities Officer to share
information related to accommodations that you require with others (professors, advisors and
counselors) on a “need to know” basis. If you agree, the Disabilities Officer will prepare letters
concerning appropriate accommodations for your professors and advisor.
Yes, I agree that the Learning Center arrange my accommodations, sharing
information only as needed once I have provided all of the necessary documentation.
No, I am not requesting accommodations at this time.
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Disabilities Disclosure and Request for Accommodation If you (Pfeiffer University)

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Completed 6 August 2021

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