Notification of Accommodation Request Form

1

Student Name* This field is required.

First Name

Last Name

2

Student ID#* This field is required.(Your 900#)

900#

3

VCCCD E-mail* This field is required.(Your School email address)

example@my.VCCCD.edu

4

Phone Number - Best Number to Contact You* This field is required.

5

Please List the Term (MUST be current), Class and Instructor's Name* This field is required.Make sure the class, or classes, you are requesting accommodations for are for THIS semester. All requests for NEXT semester will not be completed. DO NOT request accommodations for your classes more than two weeks before the class begins.

Term - ex. Fall, Spring or Summer

Class - ex. English R101, MATH R105, AT R103, etc.

Instructor's Name - ex. Bates, Edwards, Helfrich

6

Do you want to request a letter for another class?* This field is required.

YESNO

7

Please List the Term (MUST be current), Class and Instructor's Name* This field is required.

Term - ex. Fall, Spring or Summer

Class - ex. English R101, MATH R105, AT R103, etc.

Instructor's Name - ex. Bates, Edwards, Helfrich

8

Want to request a letter for another class?* This field is required.

YESNO

9

Please List the Term (MUST be current), Class and Instructor's Name* This field is required.

Term - ex. Fall, Spring or Summer

Class - ex. English R101, MATH R105, AT R103, etc.

Instructor's Name - ex. Bates, Edwards, Helfrich

10

Want to request a letter for another class?* This field is required.

YESNO

11

Please List the Term (MUST be current), Class and Instructor's Name* This field is required.

Term - ex. Fall, Spring or Summer

Class - ex. English R101, MATH R105, AT R103, etc.

Instructor's Name - ex. Bates, Edwards, Helfrich