Q
UINCY
C
OLLEGE
|
PLYM OUTH & QUINCY CA M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
Q
UINCY
C
AMPUS
:
617-
405-5915
F
AX
:
617-984-1792
PLYMOUTH 617-984-1731 FAX: 508-747-8169
http://www.quincycollege.edu/departments/disability-services
Revised 2/1/17
STUDENT REQUEST FOR LETTERS OF ACCOMMODATION
STUDENT NAME: ____________________________Student ID _____________ Date _________________
E-mail address: _________________________________ Phone Number: ___________________________
Semester: (check one) Fall Spring Summer (10 week) Summer 1 Summer 2
Campus: (check one) Quincy Plymouth
Please check one of the following:
I am a new student requesting Accommodations (must make appointment with DSO)
I am requesting the same Accommodations
I am requesting changes to my Accommodations (must make appointment with DSO)
PLEASE RELEASE “ACCOMMODATION LETTERS TO THE FOLLOWING INSTRUCTORS:
1. Course Number: __________________ Course Name:_______________________________________________
Teacher: _____________________________ Meeting days & times: ________
2. Course Number: _________________ Course Name:
Teacher: ____________________________ Meeting days & times: ________
3. Course Number: _________________ Course Name:
Teacher: _____________________________ Meeting days & times: _______
4. Course Number: ______________________ Course Name: _______________
Teacher: _____________________________ Meeting days & times: ________
5. Course Number: __________________ Course Name:
Teacher: _______________________________ Meeting days & times: _______
6. Course Number: __________________ Course Name:
Teacher: __________________________________ Meeting days & times: __________________________________
Student Signature: _______________________________________________________________________________
SUBMIT
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