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Accommodation Renewal Form

Name

Class Year

Banner ID#

Term/Year Requested For

First Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Second Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Third Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Fourth Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Fifth Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Sixth Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Seventh Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Eighth Course

Course Code (e.g., DWC 201)

Course Registration Number (CRN)

Professor's Name

Academic Accommodations Being Requested (i.e. extended test/quiz time)

Based on my documented disability, I am requesting academic accommodations for each one of the courses listed above.

This form is only used to request academic accommodations for which you have had prior approval by Disability Support Services (DSS) at Providence College.

Please schedule a meeting with a DSS staff member to discuss any new academic accommodation requests.

Accommodation Renewal Form

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