AS - SDC - Accommodation Request Form

Serving Students with Disabilities
SDC Accommodation Request Form

If you have been determined eligible for SDC services, please complete the form below with as much detail as possible. After the form has been submitted, your request will be processed and you will be contacted by email if your accommodations are approved. Students who are deaf or hard of hearing, please use the SDC Accommodation Request Form for Deaf and Hard of Hearing Students.

On-line submissions are not secure. It is extremely unlikely this form would be intercepted, but if utmost confidentiality is a concern, please use the PDF version which can be submitted in person, by mail, or by fax. See the Contact Us page for address and phone numbers.

Important! You should see an acknowledgment of your submission. Examine it carefully for errors. If you find any, or do not see an acknowledgment, contact the SDC at:
(530) 752-3184 (voice) or (530) 752-6833 (TTY).

Accommodations requested for:
Quarter, Academic Status,

Disability Specialist:
Student Name:
Student ID#:
Address:
City:
State:
Zip:
Phone:
E-Mail:

Check here if this is a new address and/or phone number.

I acknowledge that by requesting academic accommodations, I am authorizing the SDC Disability Specialist to discuss information relevant to the recommended accommodations with faculty and staff who have a need to know. I understand that, as with all University activities, I am required to comply with the UC Davis Student Code of Conduct, including the responsibility to accurately represent my circumstances.

A mark in this box signifies my acceptance of the above statement. I understand I will be asked to sign this form when I pick up my accommodations.

1. Course Abbrev. & No.: CRN: Units:

Instructor:

Instructor Email: