Accessibility Support Center
STUDENT REQUEST FOR AUXILIARY AIDES / PERSONAL SERVICE ATTENDANT
Name of Student Date
Student ID Phone Number
The above student is requesting an extra seat for the use of an auxiliary aide/personal service attendant during the following semester:
(Check Fall, Spring, or Summer, followed by year)
[ ] Fall Year
[ ] Spring Year
[ ] Summer Year
in the following courses:
Course Title Section Number Instructor
The following documentation from a qualified professional must be attached:
The following agency/entity will be hiring, training and supervising the aide/attendant:
Name of agency/entity Phone
Please submit to ASC Director or ASC Counselor, Room 1073
The following ASC Director/Counselor is authorizing the requested aide/attendant:
Cabrillo College makes every reasonable effort to accommodate individuals with disabilities as addressed by the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. In keeping with this commitment, Auxiliary Aides/Personal Service Attendants will be allowed entrance into the classroom.
A qualified student who requires auxiliary aide/personal care services must make arrangements to provide for his/her own auxiliary aide/personal attendant care service. The college does not assume coordination or financial responsibilities for auxiliary aides/personal attendant care services.
The student and attendant will sign the Auxiliary Aide/Personal Service Attendant agreement below. Copies will be provided to the student, attendant, instructor(s), and the Accessibility Support Center.
Auxiliary Aides/Personal Service Attendants are:
I understand and agree to the guidelines as outlined above.
Student signature Date
Auxiliary Aide/Personal Service Attendant Date
ASC Director ASC Counselor Date
Original: Student's File; Copy to Division Dean and Instructors — 5/8/2014