Clone of Accommodations Renewal Form

Accommodation Request Form

Please complete all sections of this form to ensure your request is processed. To schedule a meeting regarding your accommodations, please send your availability to accommodations@prescott.edu.
Name

First NameLast Name
Email:
example@example.com
Phone#
Format: (000) 000-0000.
Term:
Please explain diagnosis/condition to better help us help you:
Requested AcademicAccommodations (Please select all that apply):
If Other was picked, please explain:
Housing Accommodation Requests (Please select all that apply):
Supporting Documentation:
Please provide the details for each of your enrolled classes below. If your course requires an e-book, please include those specific details in the following section:
1. Course Number
Instructor's Name:
Title:
Author:
ISBN Number:
2. Course Number:
Instructor's Name:
Title:
Author:
ISBN Number:
3. Course Number:
Instructor's Name:
Title:
Author:
ISBN Number:
4. Course Number:
Instructors Name:
Title:
Author:
ISBN:
5. Course Number:
Instructor's Name:
Title:
Author:
ISBN Number:
Authorization to Release Information I hereby authorize the Prescott College Accommodation Team to verify my eligibility for academic accommodations. I have also read and agree to the handbook received.
Date Submitted:

MonthDayYear
Date
Should be Empty:

Authorization to Release Information I hereby authorize the Prescott College Accommodation Team to verify my eligibility for academic accommodations. I have also read and agree to the handbook received.