EmailMe Form - Alternate Media Request Form

Student Name *

First Last

Student ID Number *

E-mail *

Contact Phone

### - ### - ####

Semester *

List the Courses you are requesting alternate media for: *

List the Class Numbers (NBR) of the course(s): *

List the the title and ISBN for the book(s): *

DSPS Counselor (Find and click on your counselor): *

Please select the type of Alternate Media you are requesting. *

Kurzweil (text-to-speech)

Audio Book (Learning Ally)

Large Print (please note the font style and size in the comments section)

PDF

Braille

Other (please note preference in comments section)

Alternate Media Orientation (initial meeting in DSPS High Tech Center) *

I HAVE completed an alternate media orientation

I HAVE NOT completed an alternate media orientation

UPLOAD RECEIPT OR PROOF OF PURCHASE

In order for DSPS to fulfill Alternate Media requests, the following terms need to be agreed upon. Please read and check the boxes to indicate your agreement. *

I understand that I am required to provide proof of purchase or rental to verify ownership of materials. If I am not able to provide proof of ownership I should contact the DSPS High Tech Center.

I understand that I am requesting Alternate Media for textbook(s) or instructional materials that I own, rent, has been purchased on my behalf or supplied to all students at no cost.

I understand that Alternate Media is protected by copyright. Sharing or duplicating Alternate Media material is strictly prohibited.

I understand that Alternate Media requests are for San Diego Mesa College courses, (for City or Miramar; I must contact their DSPS office) I must be registered with the DSPS department and have an Academic Accommodations Plan (AAP) on file.

I understand that if I have any concerns or if I want to file a complaint about alternate media services I can contact the DSPS office (I4-405, mesadsps@sdccd.edu or 619-388-2780).

Please leave any comments or special instructions.