*All fields must be completed.

1. First Name: *

2. Last Name: *

3. Class: *

4. P.O. Box: *

5. Phone Ext.: *

6. Email: *

7. I request a foreign language substitution because of my disability (i.e. learning disability or hearing impairment), which affects my language learning in these specific ways: *

8. I understand that the intent of the language requirement is to help me achieve a reasonable proficiency in a language new to me, and to introduce me to the culture of the country or countries in which this is the primary language.  To the extent possible, I propose to meet the intent of the requirement by taking the following two courses (please specify the two courses by their name and number):

Course 1

Department Name: *

Course Number: *

Course 2

Department Name: *

Course Number: *