Accommodation Letters Request for E-Learners
Please complete the following fields.
 
Identfying Information
First Name
Middle Initial
Last Name
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Contact Information
Address1
Address2
City
State
Zip Code
Country
Email
Preferred Phone Number
Alternate Phone Number
Letter Request
For what semester are you requestion letters?
Fall
Winter
Spring
Summer
Academic Year
 
For which course(s) are you requestion accommodations? Include the course name and number and the the instructions name.
Verification and Signature
I understand that by submitting this request I am authorizing DSS to release information on a need-to-know basis to instructors and other educational support staff. I understand that this information will be used to provide me with accommodations in the courses I am enrolled.

By entering your name in the space provided, you agree that the information entered on this form is accurate and complete to the best of your knowledge.
Student Name (Please use full legal name)
Student's Initials
 
If you have problems with this form, please contact Nicole Gahagan at 262.243.4535.
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