Mt. Hood Disability Services: Student Accommodation Request Form

  
STUDENT NAME: 
   
STUDENT ID NUMBER:  
  
DATE: 
 
TERM: Fall Winter Spring Summer YEAR:

 * I WANT THE SAME ACCOMMODATIONS I HAD LAST TERM* 

If you need to add additional accommodations, please schedule an appointment with the Coordinator of Disability Services by calling 503-491-6923.

                                                                              
Student Signature
TO BE COMPLETED BY DSO STAFF
Instructor Notification Form Completed  
Date:            
                                                         
        DSO Staff Signature
© 2014 Mt. Hood Community College | 26000 SE Stark St. | Gresham, OR 97030 | 503-491-6422
 Last Modified: 3/24/2010 10:27:00 AM