Fillable Alternate Media Request Form (Woodland Community College)

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Alternate Media Request Form (Woodland Community College)

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WOODLAND COMMUNITY COLLEGE
Department of Supportive Programs and Services (DSPS)
2300 East Gibson Road, Building 700, Room 764, Woodland, CA 95776
Phone: (530) 661-5797 Fax: (530) 661-5788 Email: wccdsps@yccd.edu
Alternate Media Request Form
_________________________________ ____________________________ ___________________________
Student Last Name First Student ID
_________________________________ _________________________________________
Phone Number Student Email Address
This form is used to request alternate media for textbooks you have purchased. Please review the policies listed below that
relate to alternate media requests.
1. The student must purchase each textbook, and provide proof of purchase to the Alternate Media Specialist. Without
proof of purchase, alternate media cannot be provided.
2. The student must be enrolled in the course for which alternate media is requested.
3. The student must be registered with DSPS and have a current academic accommodation plan (AAP) that includes
alternate media or assistive technology as an approved accommodation.
4. For requests of materials other than textbooks, the student must possess and provide a copy of the material for which
alternate formats are requested.
5. If DSPS must scan a copy of the student’s book, permission must be given for the book’s binding to be removed and
for the book to be re-bound with comb binding.
6. DSPS cannot be held responsible for replacement costs or damages that may occur as a result of conversion to alternate
media formats.
7. DSPS cannot be held responsible for changes in book versions, cancellations of classes, or other unforeseen events that
can occur. The student is solely responsible for ensuring the accuracy of materials/textbooks provided to DSPS for
alternate media conversion requests.
8. The student cannot copy or reproduce any alternate media material provided by DSPS, nor allow anyone else to do so.
Misuse of this material may result in disciplinary action by WCC administration, and can jeopardize future services
with DSPS. Unlawful distribution of material can also result in legal action by textbook publishers.
9. New alternate media requests must be made each semester, and it may take up to two weeks to fulfill requests after
the request is made and proof of purchase is provided.
I understand and agree to the policies and procedures listed above.
_________________________________________ ____________________________
Student Signature Date
Please complete the back of this form to add required information for each of your textbooks.
Academic Year:____________ Summer Fall Spring
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Please complete the form below by adding all information for your purchased textbooks.
Class:
Instructor:
Book Title:
Author(s):
Edition:
ISBN #:
Office use only: Available Converted Uploaded Cut Scanned Re-bound
Class:
Instructor:
Book Title:
Author(s):
Edition:
ISBN #:
Office use only: Available Converted Uploaded Cut Scanned Re-bound
Class:
Instructor:
Book Title:
Author(s):
Edition:
ISBN #:
Office use only: Available Converted Uploaded Cut Scanned Re-bound
Class:
Instructor:
Book Title:
Author(s):
Edition:
ISBN #:
Office use only: Available Converted Uploaded Cut Scanned Re-bound
Class:
Instructor:
Book Title:
Author(s):
Edition:
ISBN #:
Office use only: Available Converted Uploaded Cut Scanned Re-bound
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Alternate Media Request Form (Woodland Community College)

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Completed 25 July 2020

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