Center for Access and Accommodative Services Rooms A125, A137, and A141
Monday Thursday 8:30-6:30 Friday 8:30-3:00 (708)456-0300 ext. 3917 and ext. 3636
Semester_____________________ Year__________________ Date_________________
Name:________________________________________________________________________________
Address _________________________________ Town __________________ Zip Code ____________
E-mail Address________________________________________________________________________
Cell Phone _________________________ Home Phone ______________________________
I am working on: ____ Associate in Art or Science Degree ____ Non-degree/transfer courses ___GED
____ Associate in Applied Science Degree ____ Continuing education courses
____ Career Related Certificate ____ ACHIEVE Certificate
My Major is __________________________________________________________________________
List the courses for which you
are requesting accommodations. (Example; COL102.001)
Note: Accommodations will be activated ONLY for the classes listed below:
_________
__________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
Approved services I am requesting: ___ Testing Accommodations ___ Kurzweil
__
Sign Language Interpreters ___ Record Lectures ___ Sonocent
___Assistance crossing 5
th
Avenue ___ Other _______________________________________
___Note-taking Services in the following classes. (Example; COL102.001)
_________
__________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
L\CAAS Forms\Request for Services 2019 10/2018
Office Only:
Colleague #: ________________________________________________
PHIN Services:
_________
__________________________________________________
____ Retrieve Inactive File ____Needs retraining ____Needs Card
Sticker:
P
acket:
PHIN Codes:
TES
TING RULES: Done
D
ate___________________
Request for Services
To activate your accommodations for the upcoming semester,
you must submit this form and bring your CAAS card to A-125
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