Public Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Please use your university issued email address

Phone Number

Current Class Level

Are you registered to vote?

Are you a Veteran?

Year of enrollment/program start date

Anticipated year of graduation/program completion date

How did you Learn about ARC Services?

For example, Admissions, Orientation, Professor, Course Syllabus, another Institution, etc.

Specific Accommodation Information

Diagnosis

Select all that apply

How does your disability affect you academically?

Please use this box to tell us how the diagnosed disability / medical condition described is currently impacting your functioning and causing you substantial limitations.

Considering the skills such as reading, writing, paying attention, mathematics, etc., describe (be specific) the current (or recent) impact of the disability/medical condition in both of the following areas:

a. In Class - lectures, labs, test-taking, participation, etc.

b. Out of Class - private study, time management, homework, daily living and accommodation/residence needs etc.

Have you used resources, services and accommodations in the past? If yes, please give as much information as possible.

What accommodation(s) are you requesting?

Semester for which accommodations are being requested

Year (specify)

Upload supporting document(s)

Click 'Upload file' then browse to your Documentation file and select then click 'Upload'.

The documentation submitted should be from a professional who is licensed/certified in the area for which the diagnosis is made and who is not related to the student. The documentation must be presented on the practice letterhead and signed by the examiner.

We encourage you to upload the documentation file below if it is available electronically as this will speed up our review process. However, if your documentation is not available electronically or if you prefer, you may mail the documentation to:

Accessibility Resources Center
University of North Carolina Pembroke
PO Box 1510, Pembroke, NC, 28372

or send by fax to 910-521-6891.