4. Describe how your impairment(s) impact(s) your functioning. ____________
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5. What accommodations are you requesting at Pepperdine University?
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6. Describe in detail the accommodations you have received in the past,
including the nature of the accommodation(s), the names of providing institutions,
and the dates provided.
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7. When, where, and by whom were you most recently evaluated/treated for the
condition(s) that cause your impairment? Please indicate the title and credential of
the evaluating professional.
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Thank you for your cooperation. You will find specific information on our website,
www.pepperdine.edu/disabilityservices, about the type of documentation necessary
for each type of impairment. If you have any questions, please contact us directly
at 310-506-6500.
A review of your documentation relating to your request will not be commenced until
this form and all supporting documentation have been received. We do not review
materials until your file is complete. Upon receipt of all documentation, your file will
be reviewed, a process that typically takes no less than 14 days. PLEASE DO NOT
SEND ORIGINAL COPIES OF DOCUMENTATION. WE DO NOT RETURN
MATERIALS ONCE SUBMITTED.
By signing below, you are initiating your request to be established as a student with
a disability in accordance with federal and state regulations.
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Student initials Date