Semester Accommodation Request Form

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Fields marked with * are required.








Please indicate every semester you will need services for the school year.
Semester Accommodations being requested:*





Name*




numbers only, no spaces, and include area code

numbers only, no spaces, and include area code





In case of Emergency, who may we contact?


numbers only, no spaces, and include area code

Did you receive accommodations last semester?*

Are you planning to return next semester?*



National Voter Registration Act: If you require assistances re-certifying, renewing, or changing your address please check one:*

Student Agreement

  • I understand the responsibility for obtaining reasonable accommodations in the classroom is mine.
  • I understand if I am requesting new accommodations, I must meet with my DS Counselor prior to having these accommodations approved.
  • I understand that if I am testing in the Disability Services, a completed testing form signed by myself and myinstructor must be submitted to the Disability Services three (3) days prior to each exam. I also understand that during finals, I am encouraged to have the testing request forms submitted at least one (1) week in advance.
  • I understand that I am responsible for following the Disability Services policies and procedures outlined in theDisability Services Student Handbook and that failure to comply with these policies and procedures may resultin my not receiving accommodations.
  • I understand that if I request note taking services through Disability Services, my e-mail address will be postedin the Note Taker Packet. (If this is a problem, please speak with your DS Counselor.)
  • I understand that my SEMESTER ACCOMMODATION LETTERS will be sent to my instructors, unless awritten letter has been given to the office stating otherwise.
  • I understand it is my responsibility to discussed my semester accommodation letter with my instructor at thebeginning of the semester. (ACCOMMODATIONS ARE NOT RETROACTIVE.)

I agree to and understand the conditions stated above.

Enter first and last name