Accommodation Request

* indicates a required field

Student Information

Welcome to the University of Pikeville Disability Resource Center. In order to receive accommodations, students must complete the following form and attach documentation of disability. If you have any questions about what type of documentation to include, please review the university’s documentation guidelines at

Students are advised to submit a request with documentation at least two weeks in advance of when they would like accommodations to be implemented. Please note that some accommodations may take longer to implement than others. If you have any questions please contact us at

Please read all instructions carefully when completing this form. You MUST COMPLETE ALL FIELDS before submitting this form.

Please use legal name.
Please use your university issued email address

Disability and Accommodation Information

Please indicate the type of accommodation(s) you are requesting.Required
Specify all that apply.

Are you a student athlete?Required

Specific Accommodation Information

Confidentiality AgreementRequired

Information provided to the Disability Resource Center (DRC) is protected by FERPA and granted the same level of confidentiality as other student records, which may only be shared with other institutional employees/departments on a “need to know” basis or with your written permission.


In order to determine reasonable accommodations and to coordinate your academic adjustments/accommodations, the DRC will need to communicate with university’s administration, faculty and/or staff. Information that is shared will be limited to only essential information (i.e. that you have a documented disability and what accommodations you are eligible to receive).


I give permission for the staff of the DRC to share information about my disability-related needs on a need-to-know basis. I understand that this authorization may be withdrawn at any time submitting a written, signed, and dated request to the DRC staff.

Have you used accommodations in a previous setting?Required
Upload supporting document(s)

If you have documentation of your disability, please upload it here. If you do not have documentation, please review our documentation guidelines here: