Accommodation Request Form

Students must complete the Accommodation Request Form. This form provides students an opportunity to describe their disability and the accommodations they are requesting. Students MUST provide appropriate documentation in order to receive services. If you need more information or have questions, please contact Dr. Megan Moeller at mmoeller@wilsoncc.edu or at 252-246-1435

Student's Name

First NameLast Name

WCC Student ID

WCC Student Email

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Semester you are requesting accommodations for

Year you are requesting accommodations for

What disabilities/medical conditions do you have?

Please describe your disability/medical condition and the impact it has on you. Include how your disability will affect you in class/on campus. Be specific and include as much detail as possible.

What types of accommodations/services are you requesting?

What types of accommodations/services have you received in the past? Please list any accommodations you may have received in the past at other schools. Write none if not applicable.