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
Birthday:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
Phone#
Format: (000) 000-0000.
Term:
Please explain diagnosis/condition to better help us help you:
Requested Academic Accommodations (recommended for Online and On-Campus students) (Please select all that apply):
If Other was picked, please explain:
Requested Academic Accommodations (recommended for On-Campus students) (Please select all that apply):
If Other was picked, please explain:
Housing Accommodation Requests (Please select all that apply):
Supporting Documentation:
File Upload

Cancelof
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 appropriate section. Textbooks can be found here Info For Current Students.
1. Course Number
Session (if not a Term course)
Instructor's Name:
Title:
Author:
ISBN Number:
2. Course Number:
Session (if not a Term course)
Instructor's Name:
Title:
Author:
ISBN Number:
3. Course Number:
Session (if not a Term course)
Instructor's Name:
Title:
Author:
ISBN Number:
4. Course Number:
Session (if not a Term course)
Instructors Name:
Title:
Author:
ISBN:
5. Course Number:
Session (if not a Term course)
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.
Signature
Date Submitted:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Accommodation Request Form

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.