Semester Request for Accommodations

Semester Request for Accommodations

Submit this form each semester, preferably three (3) weeks before the term begins. You may submit your request at any time, but please note that accommodations are not retroactive. Notify your CSA Advisor each time you change your schedule.

Name*

First NameLast Name

PBSC Student ID #*

Student's Cell Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

PBSC Email

example@pbsc.edu

Primary Campus*

Assigned CSA Advisor:*

I am requesting accommodations for:*

Total number of Letter(s) of Notification (accommodations) requested*

1*

	Details
Class 1: Course ID/Section Number

2*

	Details
Class 2: Course ID/Section Number

3*

	Details
Class 3: Course ID/Section Number

4*

	Details
Class 4: Course ID/Section Number

5*

	Details
Class 5: Course ID/Section Number

6*

	Details
Class 6: Course ID/Section Number

7*

	Details
Class 7: Course ID/Section Number

8*

	Details
Class 8: Course ID/Section Number

9*

	Details
Class 9: Course ID/Section Number

10*

	Details
Class 10: Course ID/Section Number

Date*

Date

Comment

I give the Center for Student Accessibility (CSA) permission to prepare my letter(s) of notification (accommodations) for my professors, to be delivered electronically. I also authorize CSA to discuss my accommodations with Palm Beach State College professors, staff, and departments as needed to ensure the provision of accommodations. I will notify CSA of any changes to my schedule and will submit a new form if my class schedule changes.

Name*

First NameLast Name