Request for Accommodations

Student Information

Please enter your information

First Name

Last Name

Middle Name

Piedmont ID

Please make sure this is a 7-digit number and include leading zeros (ex. 0004567)

Piedmont Email (@lions.piedmont.edu)

Please use your university issued email address

Phone Number

Is this an Employee request for accommodations?

Service Dog

Will you be making a request to bring an ESA to campus?

Campus

Transfer Student

Disability Information

My Disability/Disabilities

Other Disability

Please describe the ways in which your disability causes significant impairment to a major life activity (hearing, speaking, seeing, walking, thinking, learning, working, manual tasks, self-care, etc).

Please describe the impact of your disability in an academic environment.

Accommodation Information

What accommodations have been helpful to you in the past?

Which accommodations would you like to utilize at Piedmont?

List the auxiliary aids and services, including housing and/or dietary accommodations, that you believe will enable you to be included in the Piedmont community: (e.g., taped lectures, test accommodations, extra time, quiet room, help with note taking, housing, dietary, etc). Note that you do not have to use all accommodations in all settings every time.

Initial semester for which you're requesting accommodations

Agreements/Authorizations

In order to determine reasonable accommodations that enable full participation within the Piedmont College community, the College requires current and comprehensive documentation of the students’ condition from a licensed professional or health care provider that is not a family member. Please include recommendations for success in a college environment and suggested academic accommodations. This information should be sent on official letterhead from the licensed professional or the health care provider directly to Piedmont College Office of Resources and Services, PO Box 10, Demorest GA 30535.

Licensed professionals/health care provider/s from whom documentation will be sent

All documentation submitted to Disability Support Services is considered confidential

By my signature I affirm that all personal statements and documents that I am submitting in support of my request/s are true and correct. I understand that falsifying or misrepresenting facts or information may result in disciplinary action.

Authorization

I authorize the Piedmont University Office of Resources and Services to receive information from my provider or providers. I also authorize my provider, or providers to discuss my conditions with the appropriate Piedmont University personnel on an as needed basis.

I authorize the Piedmont University Office of Resources and Services to release necessary disability related information to my professors, advisor, administrative staff, dining personnel and Student Affairs personnel as needed.

I authorize Piedmont University Office of Resources and Services to discuss my circumstances with my parent or guardian (listed below).

These authorizations are voluntary and I may revoke my consent at any time through a written, signed and dated requested to the Office of Resources and Services. I understand that if I choose not to have certain University personnel notified, this may cause the accommodations I receive to be discontinued.

A student who wishes to file a complaint or grievance will find the information in the Student Handbook.

Name of Authorized Parent(s)/Guardian(s)

If you would like to authorize parent(s)/guardian(s) to discuss your circumstances with the Office of Resources and Services.