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Services for Students with Disabilities

Appendix A

 Continued Accommodation Request 

This form is for use by students who have already met with the Coordinator of Services for Students with Disabilities and established initial eligibility for accommodations based on disability. A separate request must be submitted each term, at least two weeks prior to the start of the term, or anytime you change classes or instructors.  awalker@cocc.edu. 

To Print: Please click the "Print Page" link in the footer at the bottom of this page.

Today's Date ______________________________________________________

Student Name _____________________________________________________

Student Email Address ______________________Phone # _________________

Student Mailing Address ____________________________________________

SSN or ID # ________________________________________________________

Term ___________________________________________

List the accommodations you are requesting for this term:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

If you wish to request new accommodations, or have new documentation since initially establishing eligibility, please make an arrangement with the Coordinator of SSD (383-7583 or 383-7743) or email:

List below the courses in which you are already registered for which you are requesting the above accommodations. (The instructor of each course listed will be informed of the requested accommodations for which you are eligible.)


Course # CRN # Course Name Instructor
____________ ____________ ___________________ _____________________
____________ ____________ ___________________ _____________________
____________ ____________ ___________________ _____________________
____________ ____________ ___________________ _____________________
____________ ____________ ___________________ _____________________

Student signature: _______________________________

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