Before you complete this form, please make sure you meet the following qualifications:
After you submit this form, you should hear back from us within three business days. If you do not, please contact Donald Lariviere via email (firstname.lastname@example.org).
If you need help completing this form, please contact us via email (email@example.com) or call 650-306-3259.
Confirm Email: (your firstname.lastname@example.org)
You may not need Alternate Media for all of your classes. In this section, please list the classes where you need any of the following:
The following statements describe our Alternate Media policies. Please read and agree to each one, then sign this form.