Date:                                                                                               Term: ___________
 

I hereby give permission for Columbia College Disabled Students Programs and Services Certificated Staff, to notify my instructor(s) that I have a verified disability and that I am eligible for appropriate accommodations that will facilitate my success in the classes at the community college.
Staff to follow-up with my instructor(s) regarding my progress in courses.

Student Signature_____________________________________________________

DSP&S Staff Signature________________________________________________