Accommodation Request and Consent Form

I understand that by signing this form I am giving the Disability Accommodations Committee of East Texas Baptist University consent to consider my accommodation request and discuss my documentation. In addition, if I am granted accommodations, I give the ETBU Disability Accommodation Committee permission to notify relevant faculty or staff of my approved accommodations.

I am requesting the following accommodations:

Name

Email

Phone

City/Town

State/Province

ZIP/Postal Code

Digital Signature

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