Request Form

The Dallas County Community College District Policy to comply with Section 504 of the 1973 Rehabilitation Act and the 1990 Americans With Disabilities Act (ADA) includes the provision of appropriate auxiliary aids and services to students with disabilities to ensure effective communication. If you have a disabling condition and would like to request an accommodation under this legislation, please complete this form and submit it to:

Dallas County Community College District
Distance Learning Courses - Disability Services Office
LeCroy Center for Educational Telecommunications
9596 Walnut Street
Dallas, Texas 75243-2122

ALL REQUESTS MUST BE IN WRITING. After receipt of this form, the Disability Services Office will contact you to discuss your request and gather additional information if necessary. In order to give the DCCCD sufficient time to evaluate your request for an accommodation, please return this form as soon as possible. It may be difficult to provide accommodations to you if the request is not received on a timely basis.

We recommend that your request for semester length services be submitted at least 30 days prior to the first day of class and that requests for services on a sporadic basis be submitted at least 72 hours prior to the date the service is requested.

ACCOMMODATION REQUEST FORM

Semester and Year:
Name:
Social Security Number:
Address:
City, State, and Zip Code:
Telephone Number - Daytime:
Telephone Number - Evening:
Name of Course:
Course Number:
Instructor for which accommodation(s) are being requested:
Please identify the disabling condition that requires accommodation(s):
Describe the accommodation(s) you will need to take this distance learning course. (You must enclose written documentation from a professional licensed to diagnose your disabling condition.)