Semester Request for Services

Form must be submitted each semester, preferably three (3) weeks prior to the beginning of the term.

PLEASE COMPLETE, SIGN AND DATE FORM

** PLEASE NOTIFY YOUR CSA ADVISOR EACH TIME YOU CHANGE YOUR SCHEDULE**

Last Name*

First Name*

PBSC Student ID #*

Student Cell Phone*

Alternate Phone

PBSC Email@my.palmbeachstate.edu

Primary Campus*

I am requesting accommodations for*

1 - Course ID/Section Number*

1 - Accommodations Requested - Please list accommodations you would like to use in each class*

2 - Course ID/Section Number

2 - Accommodations Requested - Please list accommodations you would like to use in each class

3 - Course ID/Section Number

3 - Accommodations Requested - Please list accommodations you would like to use in each class

4 - Course ID/Section Number

4 - Accommodations Requested - Please list accommodations you would like to use in each class

Total number of Letters of Notification requested

Comments

I give the Center for Student Accessibility (CSA) permission to prepare my letter(s) of notification (accommodations) for my professors, to be delivered electronically and to discuss my accommodations with my Palm Beach State College professors, staff and departments, as needed, to assist in the provision of accommodations.

Student Signature (I agree that typing my name is considered an electronic signature)*

Today's Date*