University of Minnesota Duluth
Disability Services & Resources
Request for Note Taking Services

Request for:  Fall___Spring___Summer____   Year_______        Today's Date_____________

Student Name _________________________________ ID#_______________

Local Address__________________________________City_____________________State_____

Local Phone _____________________________ Email:________________________________

***Have you read the Notes Module for students receiiving notes? Yes____No____    If yes, Fall____Spring____ Year______

Your year in college: Freshman_____ Sophomore _____ Junior____ Senior ____ Grad Student _____

Course Information:

Dept/Course #_______________________Section ______ # credits ______

Course Name _________________________________________________

Day(s) & Time class meets: _______________________ Class Location _________

Lab?? Yes______ No _______ If yes, do you need notes in the lab? Yes_____No_____

If yes, Lab day(s)/time _________________________ Location_________________

Instructor Information:

Instructor: _______________________________________ Office phone: ___________

Instructor's email: __________________________________ Office location _____________

**PLEASE NOTE: Filling out this form does not guarantee that you will be assigned a notetaker.
This decision is made by your DS&R counselor, case by case, based on each student's disability.

Approved by DS&R counselor: _________________________________ Date: ___________

Notetaker Information:(office use only)

Name___________________________________ Phone ________________________

Email ________________________________ Date assigned ______________________