Request for Referrals to Faculty

ONLY COMPLETE THIS FORM ONCE A SEMESTER!

Request for Referrals to Faculty for Modifications in Testing

Once you complete this form, please click submit once to avoid duplicates from sending. This form covers all courses you are registered for this semester and therefore only needs to be submitted once per semester.

Current Semester *

Fall 2021

WCC Student ID *

First Name *

Last Name *

Birth date *

Home Phone *

Cell Phone *

WCC Student Email *

Procedure to Request Testing Accommodations for Students with Disabilities - please read

Procedures to Request Referral to Faculty

Authorize

By completing and signing this form, I have made the decision to exercise my rights to testing accommodations this semester.

In doing so, I authorize the Disabilities Services Office to communicate with my professors and other college personnel to ensure I receive the appropriate services.

I have read Procedures to Request Referral to Faculty.

Lecture Recording Agreement *

Section III: Section 504 of the Rehabilitation Act of 1973 In accordance with Subpart E of Section 504 of the Rehabilitation Act of 1973, institutions of higher education may not deny a student with a known disability equal access to the institution’s programs, courses and activities when reasonable accommodations exist. A student with a qualifying disability which adversely affects his or her ability to take or read notes may be permitted to audio-record class lectures as a form of reasonable academic accommodation. Use of this accommodation is subject to the following conditions: 1.Recordings of class lectures are only for the student’s personal use in study and preparation related to the class. 2.The student may not share these recordings with any other person, database, or resource. 3.The student may not publish or quote the lecture without the written consent of the lecturer. 4.The student agrees to return all recorded lectures to the lecturer or to the Disability Services Office(if the DSO provided the equipment for the student’s use), or to destroy all recordings that were made when they are no longer needed for the class for which they were recorded. By electronically signing my name below I hereby certify that I have read and agree to abide by the recording Policy. I agree to destroy or return to the lecturer or the Disability Services Office all recorded lectures by the end of the semester or when the lectures are no longer needed to complete the courses. I understand failure to abide by the set policy constitutes copyright infringement and academic misconduct and may result in the suspension or revocation of this accommodation. I understand that this agreement will remain in effect as long as I am a student at Westchester Community College. Please type I agree in the space provided below after reading these terms.

Sign your name electronically *