You must have JavaScript enabled to use this form. Alternate Media and Additional Materials Request It is My responsibility to inform SSD immediately if there are any change in my class schedule that will affect my request for alternate media. It is My responsibility to submit any materials requested as quickly as possible to SSD in order to expedite the production of my alternate media. It is My responsibility to check my campus email regularly for communications regarding the status of my alternate media. I am Aware that this request form is only for course material Including; textbooks, course packets, handouts and PowerPoints as listed on the official course syllabus and/or the CSUSB/PDC Coyote Bookstore textbook list. I am Aware that I must complete a separate Additional Materials Request form per class as needed. I Agree to sign and submit an official Copyright Agreement Form for each textbook prior to the release of my accessible materials. I Understand that I must provide proof of purchase (official Receipt from vendor) for each textbook I am requesting in accessible format. Student Information First Name Last Name Coyote ID CSUSB Email Phone Number Phone Type - Select -HomeWorkCell Term Information Campus Main CampusPDC Campus Request Term - Select -FallWinterSpringSummer - RegularSummer - 6W1Summer - 6W2 Request Year Request Year: Year Year2019202020212022 Courses You Would Like Alternate Media For Number of Courses - None -12345 Course 1 Information Course Professor Class Number Section Number of Materials for This Course - Select -1234 Type of Material 1 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 2 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 3 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 4 Material Article Course Packet PowerPoint Syllabus Textbook Other Preferred Format Method of Delivery Kurzweil Files File Sender-2 Download Link Course 2 Information Course Professor Class Number Section Number of Materials for This Course - Select -1234 Type of Material 1 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 2 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 3 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 4 Material Article Course Packet PowerPoint Syllabus Textbook Other Preferred Format Method of Delivery Kurzweil Files File Sender-2 Download Link Course 3 Information Course Professor Class Number Section Number of Materials for This Course - Select -1234 Type of Material 1 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 2 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 3 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 4 Material Article Course Packet PowerPoint Syllabus Textbook Other Preferred Format Method of Delivery Kurzweil Files File Sender-2 Download Link Course 4 Information Course Professor Class Number Section Number of Materials for This Course - Select -1234 Type of Material 1 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 2 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 3 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 4 Material Article Course Packet PowerPoint Syllabus Textbook Other Preferred Format Method of Delivery Kurzweil Files File Sender-2 Download Link Course 5 Information Course Professor Class Number Section Number of Materials for This Course - Select -1234 Type of Material 1 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 2 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 3 Material Article Course Packet PowerPoint Syllabus Textbook Other Type of Material 4 Material Article Course Packet PowerPoint Syllabus Textbook Other Preferred Format Method of Delivery Kurzweil Files File Sender-2 Download Link Student Signature