Ithaca College Student Accessibility Services
Alternate Format Request Form
Student Information
Name:
ID#:
E-mail:
Telephone:
Registration/Enrollment
I have or will register or enroll in the academic term identified below:
Fall ___________
Spring ___________
Summer ___________
Other ___________
Acquisition of Standard Instructional Material in Original Format
A and B MUST be substantiated and documented on the back
for each request or request cannot be processed:
A
B
I have purchase, ordered or received the standard instructional material.
Copy of “Proof of Purchase” or “Receipt” has been provided to SDS.
Student Signature: ___________________________________________________________________________
SAS Alternate Format Request Form
Course
Number/Section
Instructor
Book Title
ISBN
Course
Number/Section
Instructor
Book Title
ISBN
Course
Number/Section
Instructor
Book Title
ISBN
Course
Number/Section
Instructor
Book Title
ISBN
A
B
Receipt
Provided
A
B
Receipt
Provided
A
B
Receipt
Provided
A
B
Receipt
Provided