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Accommodations Application

Please complete this form if you are applying for accommodations as a result of a certifiable disability. Supporting documentation is required and may be attached with this application or submitted under separate cover. Any inquiries concerning disability accommodations should be directed to the Disabilities Coordinator in the Academic Affairs Office at (606) 539-4216 or 1-800-343-1609.

6170 College Station Drive
University of the Cumberlands
Williamsburg, KY 40769
Phone:  606-539-4216; FAX:  606-539-4617

 

Student Information

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County
Birthdate
Home Phone Number

 

Accommodation Information



Learning Disability
Allergies
Eating Disorder
Physical Disability
Other


Date of last assessment (Documentation within the last 3 years required)

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Name and Address of person making assessment:
   

Documentation Upload

Click here to review the Guidelines for Documentation

Please use the following fields to upload documentation of disability. You may alternatively submit documentation via FAX, email, or postal mail using the following:

6170 College Station Drive
University of the Cumberlands
Williamsburg, KY 40769

FAX:  606-539-4617

Email: tom.fish@ucumberlands.edu

 
 
 
 

Additional Information

What accommodations have you received in the past related to your disability?

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2.
3.

What accommodations or auxiliary aids do you request?

1.
2.
3.

Verification and Submission

This application may not be processed until appropriate documentation of disability is available. Documentation may include copies of accommodation records from your high school or previous educational institution, testing results and evaluation by a licensed psychometrician, and/or statements from a physician describing the disability and the necessary restrictions. The University's obligation to reasonably accommodate any student's disability ends where the accommodation would pose an undue hardship on the University or where the accommodation in question would fundamentally alter the academic program.

I understand an advisory committee will consider the accommodations requested and that the documentation provided will be reviewed by the administration, staff, and faculty who serve on the committee.

 



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