Request for Accommodations

Name:*

First Last

Student ID:*

FXUA Email:*

For which term are you requesting memos?

Memo Request

How many memos do you need?

Memo Request

I agree to sign the Academic Accommodation Memorandum*

Below is a list of student responsibilities. Please initial each box to indicate that you have read and understood each responsibility. Make sure to put your initials in each box.

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I agree to make an appointment with each instructor to review the Academic Accommodation Memorandum.*

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I agree to talk to each of my professors about the accommodations he/she will make and to ensure the professor agrees with the accommodation request. I also agree to have each professor sign the Academic Accommodation Memorandum and return each of the forms back to the Student Affairs Department with all required signatures.*

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I agree to notify the Student Affairs Department if I experience any difficulties with the agreed upon accommodations.*

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I agree to request memos every semester and when adding new classes.*

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Phone

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Request for Accommodations Form