Alternate Media Agreement
Revised 1/12/16
Once you have completed this form in its entirety, please print, sign, or e-sign, and submit it to the
Office of Student Access and Wellness.
Tel: 866.974.5700 Ext. 20050
Fax 866.251.5407
access@ashford.edu
Student Information
Student Name: ________________________________________________ Student ID: _______________________
Student Agreement
Alternate Media
I, ________________________________________, verify that I have a disability which impacts my ability
to access print media and agree to the following terms and conditions regarding Alternate Media use
as a student of Ashford University:
I have a disability that prevents me from using texts in print, and therefore, I request receipt of my
texts in an alternate format.
I will not use, further distribute, or copy these alternate media files for any other purpose.
I will abide by the Copyright Law of the United States of America, as amended (17 U.S.C Sec 101
et seq.), and the applicable Student Community Standards of Ashford University.
I understand the publisher owns all rights to the works and the alternate media files for the works,
including copyright; I only have the right to use the alternate media for the purposes set forth in this
request.
I agree to purchase requested works and provide verification of purchase at least 2 weeks in
advance of the start date of each course for which alternate media is requested.
Bookshare
Bookshare is a non-profit ebook library that is free to students with a qualifying print disability. Visit
Bookshare for additional information and questions regarding Bookshare services.
I am interested in Bookshare services and would like more information. I understand that I must
have a documented print disability (e.g. blindness, low vision or dyslexia) to be eligible for this
service.
I am not interested in Bookshare services.
Student Consent
I verify that the aforementioned information is complete, true, and correct, and by signing this form
and receiving alternate media items, I am agreeing to abide by these terms.
Student Signature: _________________________________ Date: ____________________
You have provided your consent to receive documents from Ashford University in electronic form as
part of your Online Application. For more information, please refer to the Electronic Communication
section of the Catalog.
