Accommodation Request Form

Disability Support Services

Student: It is your responsibility after registering for classes each semester to submit this
completed form to the DSS office in order to have your Student Accommodation Notice sent to instructors.

    Full Name *      
 Student ID# *     
 Date Submitted  
      Please select the Term for which you are applying
  *   Summer 2017     Fall 2017     Spring 2018
Students will need to fill out the table below with their information

Student Schedule

COURSE

COURSE ID

SECTION #

CAMPUS

INSTRUCTOR

Select your course prefix for Course One -

Press enter to access the combo box and press enter again after making your selection

Course One ID - Enter your course ID, such as 111

Course One Section - Enter your course section number, such as 0001

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Enter the name for the Instructor for this course

 

Select your course prefix for Course Two -

Press enter to access the combo box and press enter again after making your selection

Course Two ID - Enter your course ID, such as 111

Course Two Section - Enter your course section number

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Enter the name for the Instructor for this course

 

Select your course prefix for Course Three -

Press enter to access the combo box and press enter again after making your selection

Course Three ID - Enter your course ID, such as 111

Course Three Section - Enter your course section number

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Enter the name for the Instructor for this course

 

Select the Course Prefix for Course Four -

Press enter to access the combo box and press enter again after making your selection

Enter the Course Four ID

Enter Four Section Number

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Instructor for Course Four

 

Select your course prefix for Course Five -

Press enter to access the combo box and press enter again after making your selection

Course Five ID - Enter your course ID, such as 111

Course Five Section - Enter your course section number, such as 0001

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Enter the name for the Instructor for this course

 

Select your course prefix for Course Six -

Press enter to access the combo box and press enter again after making your selection

Course Six ID - Enter your course ID, such as 111

Course Six Section - Enter your course section number, such as 0001

Select the campus at which this course meets (or online) -

Press enter to access the combo box and press enter again after making your selection

    

Enter the name for the Instructor for this course

 




Please note - Any changes in your schedule should be reported immediately to Disability Support Services

Check to have your Accommodation Notice sent to the Individualized
Learning Center (ILC)
* Yes No

Check to have your Accommodation Notice sent to the Elearning Testing
Center (ELTC)
*    Yes No

 Typing your name here acts as your signature in an electronic version and gives DSS permission to send your Student Accommodation Notice to the instructors indicated above.

Student Signature *    Wake Tech Email: *

Preferred Contact Number * (XXX-XXX-XXXX)