Date Submitted:
MM DD YY
_______________________________
_______________________________
_______________________________
_______________________________
REQUEST FOR ACCOMMODATION FOR RELIGIOUS OBSERVANCES
This form must be submitted by the student to the instructor as soon as possible and, except in unavoidable
situations, at least one (1) week in advance of a planned absence. Students must submit a separate form to each
course instructor the accommodation request will impact. The instructor and student are responsible for signing
this form once the religious observance accommodation is determined; it is recommended that both parties retain
a signed copy for their records.
Student ID Number:
Name:
Campus Location:
CCAC Email Address:
Term of Accommodation
Requested:
Circle One: Fall Spring Summer Year:
Department/Instructor’s Name:
Course Number, Name and Section:
ACCOMMODATION FOR OBSERVANCE DURING THE TERM
Date of Absence
Requested Accommodation
Agreed Upon Accommodation
It is understood that this information will be treated in a confidential manner, except to the extent that the
information is false, fraudulent, required to be used in any claim of academic misconduct against the student or
required to be disclosed to defend CCAC in any claim or potential claim involving the student or the suspicion
of fraud.
Student Signature:
Date:
Instructor Signature:
Date:
CC: Office of Institutional Diversity & Inclusion (OIDI)
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