DATE RECEIVED:_______________ Check one- Please give to ___Marie Cooper OR ___Marge Zipin

REQUEST FOR ACADEMIC ADJUSTMENTS
THIS FORM MUST BE COMPLETED EACH SEMESTER
Instructions: Complete this request and return it to

disAbility Services
Student Services Center
Room 14 Rollins
Bucks County Community College
275 Swamp Road, Newtown, PA 18940

At least two weeks before classes begin.

Letters for your instructors will be prepared and sent to you for you to present to and discuss with them during the first week of classes. Late requests will result in your letters arriving after classes begins.
PLEASE PRINT

Student Name:_______________________________________Student #____________________
Address:________________________________________________
Town:___________State:_______ Zip:_____________ Telephone:____________________

Academic Adjustments Requested:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Semester Schedule: Fall______Spring______Summer______Year______

Course # and Section-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- Day & Time
(example MATH 095.01)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Please Note: I understand that is my responsibility to notify the Disability Office of any changes in my schedule. I have the right to appeal any decision regarding academic accommodations that is made by Disability Services Staff. The appeal process form and information may be found on our website: www.bucks.edu/disability or ask for a copy from DS staff.

Students Signature:_____________________________________ Date:__________