Moodle Special User Request Form
Authorized staff use this form to request Moodle accounts for special users. Regular degree-program students must be submitted to the Director of Digital Learning with full biographical information.
Firstname *
Please enter the first/given name for the account requested.
Your answer
Lastname *
Please enter the last name/family name for the account requested.
Your answer
Email *
Please enter the email address for the account requested.
Your answer
School *
Please enter the school or of primary affiliation.
Degree or Certificate Program *
Please select the degree or certificate program below.
Is the user Temporary? *
Please select the appropriate status (A= Active, T=Temporary)
If temporary, please enter the account end date.
If this request for a temporary user account, please enter the ending date (for example, a student taking a one-week course only).
City, State *
Please enter the location of the student in city, state format
Your answer
Your name? (authorized users only) *
Please enter your name and contact information if we have any questions regarding this request.
Your answer
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