Request for Room Accommodations

Please use this form to request accommodations for the physically impaired students in your classroom.

Please Note: Only accommodations approved by a learning specialist will be provided. Please contact Disability Services for more information.

*Required

Your Information:

First Name*:

Last Name*:

email*:

phone*:

ext.

Preferred method of contact*: email phone

Status*:

Learning Specialist*:

This request is being made by someone other than the person listed above
(If you checked this section, please list your name and relationship to the person listed above in the comments box below)

Course Information*:

Course Name:

Course Ref. No. :

Semester:

Location :

Bldg: Room:

Instructor Information :

First Name*:

Last Name*:

phone*:

ext.

email:

Accomodations Requested*:

Equipment:
  Windows users:
      Control-click for more items
  Macintosh users:
      Command-click for more items

If "Other" please indicate Accommodation(s) below under notes

Comments:

Adjustable Height Table
Adjustable Height chair
Other