SOUTH PUGET SOUND
COMMUNITY COLLEGE
ACCESS SERVICES
ACCOMMODATION REQUEST FORM
Quarter for which accommodations are being requested:
SUMMER FALL WINTER SPRING
NAME: STUDENT ID: DATE OF BIRTH:
ADDRESS: CITY: STATE: ZIP:
PHONE: EMAIL:
LIST THE CLASSES FO
R WHICH YOU NEED ACCOMMODATIONS
(please fill out completely):
ITEM # COURSE ID BLDG RM DAYS TIME INSTRUCTOR ACCOMMODATIONS
Sample
2352
ENG 101 22 250
M T W TH F
9-9:50 STAFF
Testing, Alternative furniture, Note taker, Sign Language
Interpreter, other
If you are not receiving your approved accommodations, or if they unexpectedly stop,
it is your responsibility to contact Access Services so we can address the issue as soon as possible.
I understand that I must request accommodations EVERY QUARTER I am enrolled at SPSCC.
I also understand that I am to request accommodations as soon as I am officially enrolled in classes.
(It can take up to two weeks to process accommodation requests.)
X
Signature Date
Date Received
Office Use Only
QTR:
