Office of Special Services Large Print Request Form Semester:__________________________________ COURSE MATERIAL: * Check one box Name:____________________________________ ID:_______________________________________ : Phone:____________________________________ : E-mail:____________________________________ : Request Date: ______________________________ : Date Needed:_______________________________ Course:____________________________________ Chapters/Pages: _____________________________ Date Received: ______________________________ TEXT BOOK WORKBOOK HANDOUTS DOCUMENTS NOTES ENLARGEMENT OPTIONS: ELARGEMENT%:_____________ (Photocopying) FONT SIZE:__________________ CONTRAST:_________________ (boldface/reverse type) STYLE:______________________ SPACING:____________________ ALIGNMENT:_________________ PAPER COLOR: ______________ *Students: Please let us know if you would like us to include the table of contents, index and/or appendix Signature: _____________________________ Date: ___________________ FOR OFFICE USE ONLY Verified for accommodations Copy of course syllabus Copy of registration receipt Copy of book receipt Scan Book Book rebound Yes No Requested from ATPC/AMX/RFBD/HTC Library/Bookshare.org CALL FOR PICK UP DATE/TIME: _______________________________ ALT MEDIA/EQUIPMENT PICK-UP DATE: _______________________ ALT MEDIA/EQUIPMENT RETURNED DATE: ____________________ PHYSICAL TEXTBOOK RETURNED DATE:_______________________ ALT MEDIA OWNED BY STUDENT: _____________________________ Revised: 05/07/12 OFFICE OF SPECIAL SERVICES Alternate Media/Equipment Request Checkout and Use Agreement Date: Name: _ Semester: Fall Winter Spring Summer 201___ SID#: ALTERNATE MEDIA/EQUIPMENT PROCEDURES Note: When requesting Alternate Media Formats/Equipment: Students must be approved by OSS for alternate media/assistive technology as an accommodation before services are provided. Each textbook request must be submitted to the High Tech Center with the purchased textbook. Due to copyright laws, all students are required to purchase textbooks. If a textbook needs to be scanned, it must be taken apart. State if you want the textbook rebound. Include: A copy of the book receipt. A copy of the instructor's syllabus. A copy of your current class schedule Students will be notified by telephone when requests are available to be picked up. At that time, students will complete the Checkout & Use Agreement below. At the end of each semester, alternate media must be returned to OSS (unless student provides their own CD), as they are the property of the institution. Any CD, Braille and/or equipment not returned will affect future registration and provision of services by the Office of Special Services. Due to the quantity of work involved in converting books into alternate media, please inform our office as soon as possible if you drop a class. Failure to notify may result in loss of OSS services. Equipment Checked Out: ______________________________________________________________ for the period of: _____________ to _____________. CHECKOUT AND USE AGREEMENT I, ___________________________ understand the Office of Special Services’ policy for the use of alternate media and agree to abide by the following checkout guidelines. Specifically, I will not sell, share, duplicate or distribute the alternate media material and will return all borrowed equipment to OSS by the specified date. In addition, I understand the alternate media/equipment is the property of OSS and any violation of this directive may be cause for suspension of future services with OSS, and if alternate media/equipment is not returned, a hold will be placed on my LACC registration and records. Students are responsible for paying the replacement cost of equipment that is not returned by the specified date above. By signing said agreement, I have received the alternate media/equipment, my original textbook and agree to stated guidelines. Signature: _____________________________ Date: _________________________ Emergency/Alternate Contact: Name: _____________________ Revised: 05/07/12 Phone: _____________ Email: _____________________ OFFICE OF SPECIAL SERVICES Textbook Request Form Date: Name: _ SID# : Semester: Fall Winter Spring Summer 201___ Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Book _________________________________________________________________________ ISBN: _________________ Type: CD Braille USB SD Card Large Print Revised 05/07/12