Fillable Alternative Media Request Form (Las Positas College)

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Alternative Media Request Form (Las Positas College)

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Disabled Student Programs & Services
3000 Campus Hill Drive | Room 1615, Livermore, CA 94551
(L): DSPS Data | New Forms | Final Drafts 6.10.19
ALTERNATIVE MEDIA REQUEST FORM
Please complete this Alternative Media Request Form completely with all the required
documentation in order to fulfill your request. Alternative Media requests must be aligned and
consistent with student Academic Accommodation Plans (AAP) as determined during the
interactive intake process with a DSPS counselor.
Name:
W#:
Email:
Phone:
Semester/Year:
Date:
Type of Alternate Format Requested:
Audio Book/LearningAlly
Braille Output
Electronic/Digital Book
Enlarged Print Font Size: _________
PDF Format
Other _________________________________
Book Title 1:
Required
Recommended
ISBN:
Author:
Edition:
Course:
Production Timeline:
Standard Rolling Basis Specialized
• Please attach as many additional sheets as needed for alternative media requests.
• For help completing this Alternative Media Request Form, please contact Karen Zeigler
at kzeigler@laspositascollege.edu
or by phone at (925) 424-1524.
Book Title 2:
Required
Recommended
ISBN:
Author:
Edition:
Course:
OFFICE USE ONLY
Production Timeline:
Standard Rolling Basis Specialized
Book Title 3:
Required
Recommended
ISBN:
Author:
Edition:
Course:
Standard Rolling Basis Specialized
Book Title 4:
Required
Recommended
ISBN:
Author:
Edition:
Course:
Standard Rolling Basis Specialized
Book Title 5:
Required
Recommended
ISBN:
Author:
Edition:
Course:
Standard Rolling Basis Specialized
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Alternative Media Request Form (Las Positas College)

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Completed 25 July 2020

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