Disability Services Request Form
Name: ____________________________________ RVCC ID#: G________________________
E-mail: ___________________________________ Phone #: ________________________
Please check one type of service. If you are requesting more than one service, please complete a separate form
for each request. Please allow up to at least 2 weeks’ processing time.
Requesting services for: SPRING FALL WINTER SUMMER 20____
Type of service:
Sign language interpreter
o Please specify the language (i.e. American Sign Language, etc.) ____________________________
Communication Access Real-time Translation/CART
Request for an in-person reader (Please provide a copy of the syllabus for the request.)
Request for a scribe (Please provide a copy of the syllabus for the request.)
Course/Event Information
o Course/event name (i.e. lecture, exam, etc.):___________________________________________
If this request is for an event, please specify the date: ________________________________
o Please fill in times under the day you are requesting the service
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start
End
Start
End
Start
Start
End
Start
End
Start
End
o Location of the class/event (include Building and Room) _______________________________
o Name of Professor (if applicable): ___________________________________________________
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