ࡱ> psoa bjbj** XhH=bH=b " 88888LLL8ddL<L(tttt6J Vt<v<v<v<v<v<v<$>A<8^"6^^<88tt<&&&^F8t8tt<&^t<&&66,9tN]Rh7`<<0<7A0A8,9,9A8@9 ^^&^^^^^<<&^^^<^^^^A^^^^^^^^^ B : Banacos Academic Center Disability Services  HYPERLINK "mailto:ds@westfield.ma.edu" ds@westfield.ma.edu Learning Disabilities Program  HYPERLINK "mailto:ldp@westfield.ma.edu" ldp@westfield.ma.edu Reasonable Accommodations Request Todays Date: ________________ Request for: Full academic year: _____________ (i.e., 2019-2020) OR Semester: ______________ (i.e. fall 2019, summer 2020, etc.) Name: _________________________________ UWID#: A________________ Address: _________________________________________________________ Phone: _______________________________________ Email:____________________________________@westfield.ma.edu Major 1: _______________________ Major 2: _______________________ What academic accommodations are you requesting? 50% (time and a half) for exams 100% (double time) for exams Reduced distraction environment for exams Calculator for exams Reader for exams Scribe for exams Alternate format for exams Unlimited printing E-text Note taking assistance Classroom (i.e., allowance for breaks, furniture): What other accommodations are you requesting? Housing (i.e., single in suite; residential hall with elevator): Parking: Dining: Other: Accommodation Notices Send to all instructors: ____ I would like all of my instructors to receive a notice of accommodations. OR Send for only some courses: (fill this out only if you did not check the option above) Please write in the courses and instructor names to whom we should send a notice of accommodation. Course & Section Number (i.e., ENGL 0102-001) Instructor*If your schedule changes after you have submitted your request, be sure to inform your Banacos advisor.* Which offices would you like notified and what should we tell them? Residence Life ______________________________________________ Facilities ___________________________________________________ Parking Clerk _______________________________________________ Dining _____________________________________________________ Registrar_ _________________________________________________ Other: _____________________________________________________ Is there any other information you would like us to share with other offices or instructors? (No (Yes. What information and to whom? ____________________________________ _____________________ Student Signature Date If submitting this form electronically, type in your name and the date above and send it from your email address.     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