Semester Accommodation Request Form
Semester Accommodation Request Form
Louisiana Delta Community College
Office of Student Counseling and Disability Services
Semester Accommodations being requested
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Spring 2022
Summer 2022
Fall 2022
Name
Name
*
First
Last
Student ID#
L#
Campus
*
Bastrop
Jonesboro
Lake Providence
Monroe
Ruston
Tallulah
West Monroe
Winnsboro
Phone
Phone
*
-
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-
###
####
Cell
Cell
-
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-
###
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Email
*
In case of emergency, who may we contact?
In case of emergency, who may we contact?
*
First
Last
Emergency contact phone number
Emergency contact phone number
*
-
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-
###
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Please use the space below to discuss any concerns/additional accommodations needed.
*
Are you planning to return next semester?
*
Are you planning to return next semester?
Yes
No
Do you want reminders to renew each semester?
Do you want reminders to renew each semester?
Yes
No
How would you like to be reminded?
How would you like to be reminded?
Email
Text
By selecting a text reminder, you agree to receive a text message on your mobile phone. Note message or data rates may apply.
Cellphone Carrier:
Cellphone Number:
If transferring, where are you going?
Student Agreement
*
Student Agreement
I understand the responsibility for obtaining reasonable accommodations in the classroom is mine.
I understand if I am requesting new accommodations, I must meet with my SC-DS Counselor prior to having these accommodations approved.
I understand that Accommodation Letters will be emailed to my instructors by the SC-DS office. I understand that ACCOMMODATIONS ARE NOT RETROACTIVE.
I understand that if I am testing in the Testing Center, I must schedule this service by emailing rhondalindsay@ladelta.edu or completing the online Testing Accommodations Form at 2-3 business days prior to each exam to schedule the testing appointment.
I understand that I am responsible for following the Student Counseling and Disability Services policies and procedures outlined in the Student Handbook for Disability Services and that failure to comply with these policies and procedures may result in my not receiving accommodations.
I UNDERSTAND I MUST COMPLETE THIS FORM EVERY SEMESTER THAT I ATTEND LDCC.
I agree to and understand the conditions stated above.
Type your name in the box below.
I understand this is a legal representation of my signature.
*