Fillable ALTERNATE MEDIA REQUEST FORM Please fill out this (Yuba College)

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ALTERNATE MEDIA REQUEST FORM Please fill out this (Yuba College)

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Semester: SU ____ FA ____ SP ____
Please fill out your book(s) information on the back of this form
Name: ______________________________
Student ID: ______________________________
Phone #: ______________________________
ALTERNATE MEDIA REQUEST FORM
Please fill out this form completely in order to obtain services from Alternate
Media Services. If this form is incomplete, services may be delayed. The student is responsible for submitting
proof of purchase to the Alternate Media Specialist. Without proof of purchase, alternate media cannot be
provided. Each request may take up to two weeks to process once proof of purchase is provided.
1. I agree that I am enrolled for the semester in the particular course(s) for which I am requesting alternatively
formatted instructional materials.
2. The student must be registered with DSPS and have a current academic accommodation plan each
semester.
3. Students must be approved by DSPS for alternate media/assistive technology as an accommodation
before services are provided.
4. The student must own a physical copy of the textbook or possess other material they are requesting in
alternate format (Kurzweil).
5. If DSPS scans the student’s book, the binding may have to be removed for scanning. Your book will be
rebound with comb binding.
6. DSPS will not be held responsible for any damage to the material that may occur as a result of conversion
to an alternate format.
7. DSPS will not be responsible for textbooks that are altered if your class is cancelled for any reason. We will
not be responsible for the cost of your book.
8. The student will not copy or reproduce any material provided by DSPS, nor allow anyone else to do so.
Misuse of this material will result in disciplinary action by DSPS for future services and legal action by
Publishers. Any further reproduction or distribution in a format other than a specialized format is an
infringement.
9. Remember to request alternate media services every semester at least 2 to 3 weeks prior to the start of
each semester to ensure timely delivery of materials.
I understand the procedures and conditions of service listed above. My signature is my commitment to adhere
to these responsibilities and terms.
_____________________________________________
Student Signature Date
Please fill out your book(s) information completely.
Class: __________________________________
Instructor: ________________________________ Days and Time: _________________________
Title of Book: ______________________________________________________________________
Author(s): ________________________________________________________________________
Edition: ____________ ISBN: _____________________________________________________
Office use only: Available _____ Converted _____ Uploaded ____ Book ____ Cut ____ Scanned _____ Binded ____
Class: __________________________________
Instructor: ________________________________ Days and Time: _________________________
Title of Book: ______________________________________________________________________
Author(s): ________________________________________________________________________
Edition: ____________ ISBN: _____________________________________________________
Office use only: Available _____ Converted _____ Uploaded ____ Book ____ Cut ____ Scanned _____ Binded ____
Class: __________________________________
Instructor: ________________________________ Days and Time: _________________________
Title of Book: ______________________________________________________________________
Author(s): ________________________________________________________________________
Edition: ____________ ISBN: _____________________________________________________
Office use only: Available _____ Converted _____ Uploaded ____ Book ____ Cut ____ Scanned _____ Binded ____
Class: __________________________________
Instructor: ________________________________ Days and Time: _________________________
Title of Book: ______________________________________________________________________
Author(s): ________________________________________________________________________
Edition: ____________ ISBN: _____________________________________________________
Office use only: Available _____ Converted _____ Uploaded ____ Book ____ Cut ____ Scanned _____ Binded ____
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ALTERNATE MEDIA REQUEST FORM Please fill out this (Yuba College)

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Completed 15 September 2020

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