Alternate Media Request for Course Handouts Form

Students with verified print disabilities should fill out this form to help

Fill out this electronic form below and

press the SUBMIT button at the bottom of this form to submit it via e-mail. OR
print it, sign it, and deliver it to DSPS Support Services.

You may obtain a paper version of this form, fill it out, sign it, and turn it in at the DSPS Support Services Desk.

Remember, you must click the submit button
at the bottom of the form to submit your request!

*Fields marked with a red asterisk are required

Student Information

First Name: *
Last Name: *
Phone Number: *
E-mail address:

Term Information

Semester: *
Year: *

Course One

Course Number (i.e. MATH 7): *
Section Number: *
Instructor: *
Desired Format: *

Course Two

Course Number (i.e. MATH 7):
Section Number:
Instructor:
Desired Format:

Course Three

Course Number (i.e. MATH 7):
Section Number:
Instructor:
Desired Format:

Course Four

Course Number (i.e. MATH 7):
Section Number:
Instructor:
Desired Format:

Please list any comments regarding your needs:

I request that the Alternate Media Facilitator (AMF) contact my instructors and arrange for alternate formats for course handouts. I give permission for the AMF to provide the instructor with my name and to discuss the type of disability I have with the instructor as it relates to the provision of alternate media.

If the form is filled out correctly, when you press the submit button you will be sent to a web page which confirms that your request was successfully submitted. If you are unable to get the form to validate, please print it and mail or deliver it to: Alternate Media Facilitator, DSPS, Cuesta College, P.O. Box 8106, San Luis Obispo, CA 93403-8106.