Center For Disability Services

Bouillon, Room 205 | Phone: (509) 963-2171

First Name:

Last Name:

Student ID:

Phone Number:

CWU Email Address:

Quarter requesting services for: Summer 2009 Fall 2009 Winter 2010 Spring 2010 Summer 2010

Class:

Section Number:

Location:
Ellensburg Des Moines Lynnwood Pierce Yakima Moses Lake Wenatchee Kent Everett Mt. Vernon

Service Requested 1st Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 2nd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 3rd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Comment:

Class:

Section Number:

Location:
Ellensburg Des Moines Lynnwood Pierce Yakima Moses Lake Wenatchee Kent Everett Mt. Vernon

Service Requested 1st Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 2nd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 3rd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Comment:

Class:

Section Number:

Location:
Ellensburg Des Moines Lynnwood Pierce Yakima Moses Lake Wenatchee Kent Everett Mt. Vernon

Service Requested 1st Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 2nd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 3rd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Comment:

Class:

Section Number:

Location:
Ellensburg Des Moines Lynnwood Pierce Yakima Moses Lake Wenatchee Kent Everett Mt. Vernon

Service Requested 1st Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 2nd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Service Requested 3rd Choice: Please select a service... American Sign Language Speech-to-Text (meaning for meaning) Speech-to-Text (word-for-word) Assistive Listening Device No Services Requested For This Class Other (Please explain in comment box)

Comment:

Important Information

• Request form MUST be filled out and submitted every quarter prior to the deadline (see CDS Calendar).
• If you request services after the deadline you must see Troy Brenner before any services can be requested.
• While do try to meet your first choice sometimes it is not possible and we will automatically go to your second choice. We also need to know your 2nd and 3rd choice in case of illness or absence of your scheduled service provider.
• After a schedule has been submitted, if you change your class we cannot guarantee your first choice.
• It is your responsibility to let CDS know of any class changes, including time changes or room changes.

I have read and understand the *Important Information*