Please read the Guidelines for Documentation before beginning this application. This link will open in a new window. Have you been accepted to UNCP? Yes No Full Name First Name Middle Initial Last Name Banner ID if current student This is your unique ID number and consists of 9 digits Are you registered to vote? Yes No Are you a veteran? Yes No UNCP Email (only) UNCP Email (only) Confirm email Phone (Home) Phone (Cell) Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date of Birth Program of study? Year of enrollment / Program start Anticipated year of graduation / program completion Education Classification Undergraduate Graduate/Professional Continuing Studies Distance Education How did you learn about ARC Services (for example, Admissions, Orientation, Professor, Course Syllabus, another Institution, etc.) Primary Type of Disability/Medical Condition Attention Deficit Hyperactivity Disorder Chronic Medical Condition Hearing Impairment Learning Disability Physical/Mobility Impairment Psychological/Psychiatric Visual Impairment Other… Enter other… Associated Limitations Concentration/Thinking Hearing Seeing Reading Speaking Understand Spoken Language Walking/Climbing Stairs Writing Type of Disability Temporary Permanent Please list any additional disabilities Historical Impact - In as much detail as possible, please describe how your impairment has affected your life in the past? Have you used resources, services and accommodations in the past? If 'yes' please give as much information as possible. Semester for which accommodations are being requested / or to start: Summer Fall Spring Year (specify) My Current Impact Statement and Accommodations Requested: Please use this box to tell us how the diagnosed disability / medical condition described is currently impacting your functioning and causing you substantial limitations. 1. 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. 2. Accommodations/Services With reference to the above information, describe the accommodations, resources and services that you think you will need and how these will address the issues you have identified above. If a written response is difficult for you, you may record your responses and submit an audio file. Documentation Please review the Guidelines for Documentation Upload documentation if available electronically 1 Click 'Choose 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 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.One file only.24 MB limit.Allowed types: txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Upload documentation if available electronically 2 Click 'Choose file' then browse to your Documentation file and select then click 'Upload'One file only.24 MB limit.Allowed types: txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Leave this field blank
