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K-12 Request Form / Students with Disabilities

If you are a School Official requesting an electronic file on behalf of a student who has a medically documented print disability that prevents him/her from using instructional materials provided by the publisher/published by Pearson Education, Inc., please complete and submit all pages of this form. Fields marked with an asterisk (*) are required.

Trouble using this form? Send an email to: k12accessibility@pearson.com

This form is for K-12 print materials only. Please follow this link for Higher Education materials: Higher Education Request Form.

Be sure to check out Pearson HTMLbooks! Compatible with assistive technology.

http://www.pearsonschool.com/htmlbooks

PART 1 INFORMATION ABOUT THE PEARSON EDUCATION MATERIAL YOU ARE REQUESTING: (Put additional ISBNs in “COMMENTS” field.)
*TEXTBOOK:   
* AUTHOR(S):   
* ISBN:   
* PUBLISHER / IMPRINT:   
* COPYRIGHT YEAR:   
* Has the book/product been adopted?   
* Has the book/product been purchased for all students?   
Please check one:   
If Other, please specify:   
PART 2 INFORMATION FROM COORDINATOR OF SERVICES / RESPONSIBLE SCHOOL OFFICIAL:
* REQUESTOR NAME:   
* TITLE:   
* EMAIL:   
* TELEPHONE #:   
* FAX #:   
* COURSE NAME:   
* INSTRUCTOR'S NAME:   
PART 3 STUDENT'S SCHOOL INFORMATION: Please do not provide any student information other than what is requested below: (One form must be filled out for each student.)
* SCHOOL NAME:   
* SCHOOL ADDRESS:   
* CITY:   
* STATE:   
* ZIP CODE:   
* COUNTRY:   
* STUDENT'S DISABILITY:   
PART 4 REQUEST TYPE: *PLEASE CHOOSE ONE
 
 
PART 5 REQUEST TO DUPLICATE A FILE PREVIOUSLY PROVIDED BY PEARSON:
* Has the file been previously provided to another student at your school?   
If yes, date of original request:   

Altough the file may have been previously provided for use by another student at your school, this request for use by another student must still be presented to Pearson.

 

UPON ELECTRONIC RECEIPT OF VALIDATION FROM PEARSON EDUCATION, INC., YOU ARE PERMITTED TO OBTAIN THE FILE FROM YOUR SCHOOL'S CENTRALIZED LOCATION, PROVIDED ALL CRITERIA ON THIS FORM HAVE BEEN MET.

In exchange for the free distribution of an electronic file for use by a student with a print impairment, Pearson is entitled to an assurance that a print textbook has been purchased on behalf of the student. Pearson reserves the right to monitor and enforce this requirement.

* PART 6 VERIFICATION AND AGREEMENT:

I verify and agree that:

1.      The requesting school or disabled student has purchased the above named printed work (the "Title").

2.      The student is registered to take or attend the above course requiring the use of the Title.

3.      The student has a disability that prevents him or her from using the Title.

4.      The request is made or supported by the Coordinator of Services for Students with Disabilities or other appropriate school official.

5.      The Title has been determined to be essential to the student's successful completion of the course.

6.      The student and the school will not use or further distribute or copy the electronic files for the Title for any other purpose.

7.      In using the electronic files provided by the Publisher, the disabled student or school official will abide by the Copyright Law of the United States of America, as amended (17 U.S.C. Sec 101 et seq.) and the applicable code of conduct and policy of the requestor's school.

8.      Pearson Education, Inc. owns all rights to the Title and the electronic files for the Title, including copyright. The student and the school have only the right to use the electronic files for the purposes set forth in this request.

This file is being provided for use by one student with a disability at your institution who is the specific subject of this request. You agree no to otherwise reproduce, use, sell, transmit, publish, broadcast, or otherwise disseminate or distribute the file (or any version modified for accessibility purposes) to anyone, including but not limited to other students with a disability at your or any other institution, others in the same company, school, college or other organization, whether or not for a charge or other consideration, including but not limited to use in connection with the sale, retransmission, distribution, publication, broadcasting, circulation or other dissemination, for any purpose, whether commercial or otherwise, without the express prior written permission of Pearson Education, Inc.

EXCHANGE OF THIS OR ANY OTHER FILE, IN A MODIFIED FORMAT OR COPY THEREOF, IS A VIOLATION OF THE U.S. COPYRIGHT ACT. SEPARATE AUTHORIZATION MUST BE OBTAINED FOR EVERY USER OF THIS FILE, ITS MODIFIED FORMAT OR COPY THEREOF, AND SEPARATE PROOF OF PURCHASE OF THE TEXT MUST BE PROVIDED.

PLEASE READ THE FOLLOWING STATEMENT. BY CHECKING THE BOX, YOU HAVE MADE THE FOLLOWING AGREEMENT:

 
* REQUESTOR'S FULL NAME:   
* REQUESTOR'S TITLE (if any):   
* REQUESTOR'S E-MAIL:   
* FILES TO BE SENT TO:
 
 
 
Address:   
COMMENTS (optional):

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