Request for Equipment Loan or Adaptive Furniture
Name
Student email
Columbia College student email
Do you have a physical disability or mobility challenge?
Yes
No
Have you met with your DSPS Counselor and have a referral for Adaptive Furniture?
Yes
No
Please indicate which classes you will need Adaptive Furniture. The classes listed must match what is on your class schedule.
Rows
Course Name (EX: BIO 17)
Course Location (EX: Sugar Pine 102)
Type of Equipment
Course #1
Standing Desk
Cushioned Chair (No Wheels)
Visual Aid
Auditory Aid
Digital Recorder
Echo Pen/LiveScribe
Headphones
Other- please contact me
Course #2
Standing Desk
Cushioned Chair (No Wheels)
Visual Aid
Auditory Aid
Digital Recorder
Echo Pen/LiveScribe
Headphones
Other- please contact me
Course #3
Standing Desk
Cushioned Chair (No Wheels)
Visual Aid
Auditory Aid
Digital Recorder
Echo Pen/LiveScribe
Headphones
Other- please contact me
Course #4
Standing Desk
Cushioned Chair (No Wheels)
Visual Aid
Auditory Aid
Digital Recorder
Echo Pen/LiveScribe
Headphones
Other- please contact me
Course #5
Standing Desk
Cushioned Chair (No Wheels)
Visual Aid
Auditory Aid
Digital Recorder
Echo Pen/LiveScribe
Headphones
Other- please contact me
Submit
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