Disability Services Accommodation Request State * First Name Last Name City State Zip Daytime Phone * (###) ### #### Cell Phone (###) ### #### Email Address * Preferred form of contact * Phone Email HPTC Program/class activity for which you need accommodation * Course/Class/Activity Date * MM DD YYYY Time * Hour Minute Second AM PM Accommodation requested: * Transportion Testing Classroom Shop Other Thank you! We will contact to arrange assistance for you. To what HPTC email address should this form be sent?
