REQUEST FOR ACCESS SUPPORT SERVICES
1. STUDENT INFORMATION:
Name: ___________________________ Student ID#: ____________________ Phone #: _________________
2. STATUS (Circle all applicable):
Current Student
Prospective Student
Dual Credit
GED
TSI
HESI
3. DISABILITY/DIAGNOSIS:
My disability/diagnosis is:
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4. DETAILS OF DISABILITY/DIAGNOSIS:
A. In your own words, describe your disability/diagnosis to include challenges in everyday life.
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B.
What type of challenges do you have in the classroom setting?
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C.
What type of challenges do you have with online classes?
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D. In previous educational settings, what accommodations have been helpful, if any?
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E.
In previous educational settings, what accommodations have NOT been helpful, if any?
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F.
What accommodation(s) are you requesting Del Mar College provide?
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5. REQUEST FOR SERVICES:
I am making a formal request- as a student with a disability- for services from the college. I agree to abide by all rules,
procedures, and limits determined by the law and the college.
Signature of Student: _____________________________________________________________ Date: ___________________