Fillable Yuba College Disabled Students Programs and Services ACCOMMODATION (Yuba College)

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Yuba College Disabled Students Programs and Services ACCOMMODATION (Yuba College)

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Yuba College
Disabled Students Programs and Services
Phone: 530-741-6795 VP 866-274-7530 Email: dspsinfo@yccd.edu
ACCOMMODATION REQUEST FORM
Student Name Student ID Phone
Class
Class Code
Days
Times
Instructor First Initial/Last Name
Room #
Accommodations Requested for this class:
□ Chair □ Note-taker □ Captioner
□ Table □ Interpreter □ Other
Class
Class Code
Days
Times
Instructor First Initial/Last Name
Room #
Accommodations Requested for this class:
□ Chair □ Note-taker □ Captioner
□ Table □ Interpreter □ Other
Class
Class Code
Days
Times
Instructor First Initial/Last Name
Room #
Accommodations Requested for this class:
□ Chair □ Note-taker □ Captioner
□ Table □ Interpreter □ Other
I understand that it is my responsibility to check on the status of this request within one week of making my request.
STUDENT SIGNATURE DATE
ACCOMMODATION APPROVED BY DATE
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Yuba College Disabled Students Programs and Services ACCOMMODATION (Yuba College)

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Completed 15 September 2020

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