Disability Services Office
Note taker / Tutor / Reader / Scribe Request Form
By filling out this form, I acknowledge and understand that services are being provided to me by
the Disability Services Office (DSO). If I am picking up notes, the note taker will send the notes
to DSO within 24 hours after the class has taken place. It is then my responsibility to come to
DSO to retrieve my notes. If I fail to pick up my notes in a timely fashion and do not notify the
DSO staff, I risk losing this service. If I am utilizing the tutor, reader, or scribe services, it is my
responsibility to notify the person providing this service and DSO if I am no longer in need of
this service or if I cannot utilize this service on the agreed-upon dates.
Name:
E-mail:
Eagle ID:
Phone:
Service(s) requested:
I am requesting this/these service(s) for the following class(es):
Course name:
Professor:
Course name:
Professor:
Course name:
Professor:
Course name:
Professor:
Course number:
Professor email address:
Course number:
Professor email address:
Course number:
Professor email address:
Course number:
Professor email address:
Course name:
Professor:
Course number:
Professor email address:
For office use only:
This service will be needed (circle one):
Temporarily
For the full length
of the course
Dates of Service
Start Date:
End date: