Employer/DRC Student Name
ID #
Home Phone
Student Email
Vocational Rehabilitation Client? Yes No (If yes, please fill out VR Information)
VR Counselor's Name
VR Counselor's Phone
I am requesting a notetaker for the following classes during the semester:
Course Prefix & Number
Course Title
Day(s)
Start Time
End Time
I have read, understand, and agree to the information and terms in the accompanying document: "How to Obtain a Notetaker."
By submitting this form, I agree that all information provided is valid to the best of my knowledge.