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