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Application for Services: Shasta College Disability Service Programs for Students The Disability Service Programs for Students (DSPS) facilitates accommodations and services for students with documented disabilities who intend to pursue coursework at the main campus or any of its extended education sites. A variety of accommodations and services are available which afford eligible students the opportunity to participate fully in all aspects of college programs and activities through reasonable accommodations. By completing this form, I am applying for Disability Service Programs for Students PLEASE PRINT Date ___________________________________
_____________________________________________ ___________________________________________ ____________ Last Name First Name Middle Initial _____________________________________________ __________________________________ _____________________ Street Address City Zip __________________________________ ____________________________________ __________ - _________ - __________ Home Phone Cell or Other Phone Social Security Number Birth date _________/__________/__________ Age __________ Gender: o Female o Male List your Disability(ies): _________________________________________________________________________________ __________________________________________________________________________________ o I think I have a learning disability but have never been testedo I have been tested for a learning disability and can provide necessary documentationAre you a client of Far Northern Regional Center? o No o Yes Service Coordinator Name ______________________________ Phone ___________________ Are you a client of the Department of Rehabilitation? o No o Yes Counselor Name ______________________________________ Phone ___________________ Are you a client of Shasta County Mental Health? o No o YesHave you ever received services for students with disabilities at any other college? o No o Yes College_____________________________________________ Mailing Address ________________________________ City _________________________ State _______ Zip ___________ Phone __(____)_______________ Fax __(____)________________ Are you receiving services or funding from any of these campus or community programs? SSI/SSDI o Financial Aid/Scholarship o CalWORKs o EOPS / CARE oSTUDENT RESPONSIBILITIES What you will do to receive services from the DSPS STUDENT RIGHTS My participation in the Disability Services Programs for Students (DSPS) shall be entirely voluntary. Receiving support services or instruction through the DSPS shall not preclude me from also participating in any other course, program, or activity offered by the college or from receiving basic accommodations required by state and federal law. All records maintained by the DSPS personnel pertaining to my disability(ies) shall be protected from disclosure and shall be subject to all other requirements for handling of student records. If I do not comply with the responsibilities as outlined on the other side, the DSPS will notify me in writing of any impending suspension of services. The DSPS will also inform me at that time my opportunity to appeal the decision. The Shasta – Tehama – Trinity Joint Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services provided by the Disability Resource Center. Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the Chancellor’s Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict accordance with the applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U>S>C>123 (g)). Pursuant to section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. 552a note), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections 67310 – 67312, and 84850 and California Code of Regulations, Title 5, Section 5600et. Seq. NOTE: Authorities cited: Title 5 C.C.R., Section 56000 et seq., Education Code Sections 66701, 67310-67312, 70901, 84850. |
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"...Together we are learning: "...the problem is not the person with disabilities; the problem is the way normalcy is constructed to create the problem of the disabled person." Lennard J. Davis - Enforcing Normalcy: Disability, Deafness and the Body |