Furman University Student Grievance Form

To: ADA/Section 504 Coordinator
Trone Center, Suite 215
Furman University
3300 Poinsett Highway
Email Melissa Nichols

From: Student ID
Student Name
Local Telephone Local Telephone - ### - ### ####
Email
I am filing a grievance involving the following harassment or discrimination:
* Unfavorable treatment of a student because of his or her disability
* Denial and/or inappropriate implementation of reasonable accommodations
* Lack of physical access to University facilities and/or programs
* Other:

Please list other grievance(s) here
I have the following complaint:
Provide the date(s) the actions occured:
State how the action(s) is/are discriminatory (or how the decision is unreasonable if it is a denial of a requested accommodation):
This grievance is filed against the following individual:
The following individuals have information the University should consider in resolving this complaint:
I am seeking the following accommodation and/or resolution to my complaint:
Student Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date of Signing Date of Signing / MM / DD YYYY