Disability Support Services
Last Name: ___________________________________________SWC ID # ____________________________
First Name: __________________________________________Phone: ______________________________
Classroom Table Request
If you need a table placed in your classroom, check the best table height for you listed:
28” 29” 30” 31” 32” 33”
This will be the height for the bottom of the table. We will try to get as close to your requested height as possible.
Do you use a wheelchair? Yes No
If Yes, check the type of chair you use: Manual Electric
Does your wheelchair have arms? Yes No
Classroom Chair Request
Do you need a chair placed in this classroom? Yes No
If Yes, select the type of chair: A standard chair A wide chair
If you require a medically specialized chair, ie: “chair with cushion” you must first discuss this need with
your DSS Specialist.
What kind of specialized chair do you need? ____________________________________________________
Did you discuss this with your DSS Specialist? Yes No
If you checked “No” please discuss this with your DSS Specialist before you submit this form.
Indicate below the days, times, rooms and dates of each class where you need furniture placed
DAYS Start Time End Time Room # Start Date End Date
Example: MWF 8:00 AM 8:50 AM 28-112 8/18/20 12/19/20
__________ __________ _________ _______ _____________ ____________
__________ __________ _________ _______ _____________ ____________
__________ __________ _________ _______ _____________ ____________
__________ __________ _________ _______ _____________ ____________
Classrooms are in use throughout the day. This leaves limited time for the staff to
complete furniture changes. Please allow 5 working days to complete your request.
Your signature authorizes this information to be shared with Southwestern College maintenance staff.
Student Signature _______________________________________________________Date ______________
Maintenance Use Only:
Date assigned: Assigned to: Date completed: