Cabrillo College

Accessibility Support Center


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                            


Contact Person                                                                                                

Please submit to ASC Director or ASC Counselor, Room 1073

The following ASC Director/Counselor is authorizing the requested aide/attendant:

Signature                                                                           Date                      

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