Fillable APPLICATION FOR DSPS SERVICES (American River College)

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APPLICATION FOR DSPS SERVICES (American River College)

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  • 18 check-boxes
  • 52 other fields

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File type: PDF

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4/2020 SA – OnBase: DSPS Application
APPLICATION FOR DSPS SERVICES
Name:
DOB:
Student ID:
Address:
City:
State: Zip
Preferred Phone:
E-mail Address:
Emergency Contact Person
:
Relationship
to Student:
Phone: Email:
Diagnosis o
f Disability:
GENERAL INFORMATION
Major:
Other college
s attended:
If so, where
Counselor
(s)
Educational Goal: □ AA/AS
□ Certificate
Transfer to 4 Year□
□ Yes □ No
:
□
EOPS
□
Cal
WORKS
□
WorkAbility
III
□
SSI/SSDI
□
Veterans
□ Department of Rehabilitation
□
Alta Regional
□
Other
:
:
_____________________________________________________
□ Yes □ No
□ Yes □ No
:
Have you ever received services from any other DSPS/LD Office?
Are
you receiving support services through other programs? (check all that apply)
EDUCATIONAL HISTORY
How has your disability impacted your education?
Have you ever received Special Ed./504/IEP/Resource/Remedial support?
Have you ever been tested for a Learning Disability?
I understand that I must fulfill the requirements for participation in the DSPS program.
Student Signature Date
click to sign
signature
click to edit
RELEASE OF INFORMATION
The Disability Services & Programs for Students (DSPS) and Learning Disabilities Program is subject to the Federal
Family Educational Rights and Privacy Act of 1974 (FERPA) applying to the disclosure of information from student
records. This legislation and departmental policy do not allow us to disclose information about you and your
disability-related circumstances to the individual s listed below without first obtaining your written consent.
Because of the privacy requirements, we ask that you initial below each party whom we may contact to discuss
your disability-related circumstances. Please sign and date the release on the spaces provided.
COMPLETE THE FOLLOWING INFORMATION IN INK ONLY
Write
your
INITIALS
on
lines be
low.
I hereby give my consent for the staff as DSPS and Learning Disabilities P
rogram to
release
and/or receive information regarding my disability-related circumstances to the individuals/
agencies initialed below.
--------------------------------------------------------------------------------------------------------------------------------
Student ID:_________________________________
*INITIALS
*_____
*INITIALS
*College/Universities
__________________
*Testing Agencies____________________
*K-12
*Department of
Rehabilitation
*Parent(s)
*Veteran's
Administration
Parent Name:_______________________
*Medical personnel (please specify below):
*Other (please specify below):
Parent Name:_______________________
Name Name
Address Address
Phone
Phone
Print Name Birth Date
Student Signature Date
04/2020 SA
OnBase: Release of Information
____________________________________________________________________________________________
* The Learning Disabilities Program will also ask you to co-sign letters of correspondence that the Learning Disabilities Program sends to faculty, staff, or outside
agencies. Co-signature ensures that you have read the letter, understand why it is being written, and approve it for mailing. Your interests and Learning Disabilities
Program’s interests are protected under this system.
* This authorization is valid for one year from the date signed above and also subject to written revocation by the member/patient at anytime. The written revocation
will be effective upon receipt except to the extent that the disclosing party or others have acted in reliance upon this Authorization.
*
I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or
disclosure is specifically required or permitted by law.
Agencies providing information to DSPS and LD should mail it to:
ATTN: Disability Verification
Disability Services & Programs for Students
American River College
4700 College Oak Drive Sacramento, CA
95841-4286
(916)
484-8382
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signature
click to edit
Student Name:_________________________
Student ID:__________________
please print
STUDENT RIGHTS AND RESPONSIBILITIES
RIGHTS
1. My participation in the Disability Services & Programs for Students shall be entirely
voluntary.
2. 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.
3. 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.
NOTE: Authorities cited: Title 5 C.C.R., Section 56000 et seq., Education Code Sections 66701, 67310-67312,
70901, 84850.
RESPONSIBILITIES
1. I will provide the DSPS with the necessary information, documentation and/or forms
(medical, education, etc.) to verify my disability.
2. I will meet with a DSPS professional to complete a Academic Accommodation Plan,
and then meet with the professional at least annually (once per semester preferred) to
update the Academic Accommodation Plan.
3. I will utilize DSPS services in a responsible manner. I understand that the DSPS uses
written service provision policies and procedures, which must be adhered to, for
continuation of services.
4. I will comply with the Student Code of Conduct adopted by American River College.
5. I must demonstrate measurable progress toward the goals established in my
Academic Accommodation Plan.
Student Signature________________________________________ Date_______________________
Revised 04/2020 SA
I understand and agree to the above Student Rights and Responsibilities and I will abide by
them. I give permission for the Disability Services & Programs for Students staff to discuss my
educational situation with other professionals who have a legitimate educational need to
know. If I do not comply with these rights and responsibilities, I will be notified in writing of my
impending suspension of services. I will have the opportunity to appeal the decision.
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signature
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______________________________________________________________________________________________________
American River College DSPS Voter
Preference Form
Under the National Voter Registration Act (NVRA) of 1992, DSPS is an Agency-Based Registration
Site, where students have the opportunity to become registered voters during the application
process. There is no obligation to register to vote and the student's decision will have no effect on
services offered by DSPS.
To be eligible to register to vote, you must be a U.S. Citizen, and meet all eligibility requirements.
Need to check if you’re eligible? See who can vote in California.
If you are not registered to vote where you live now, would you like to apply to register to vote
here today? (Check One)
Already registered. I am registered to vote at my current residence address.
Yes.
I would like to register to vote.
If you checked "Yes", click on the following link/button to be redirected:
http://registertovote.ca.gov/?t=vra&id=3
No.
I do not want to register to vote.
NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO
VOTE AT THIS TIME.
YOU MAY CLICK THE VOTER REGISTRATION LINK ABOVE TO REGISTER
ANYTIME AT YOUR CONVENIENCE.
Student ID
1.
2.
3.
05.2020 CA - 01/13 NVRA Voter Preference Form
Applicant Name Date
Important Notices
Applying to register or declining to register to vote will not
affect the
amount of assistance that you
will be provided by this
agency.
If you would like help in filling out the voter registration form, we will help you.
The decision whether to seek or accept
help
is yours.
You may fill out the voter registration form in private.
If you believe that someone has interfered with your right to register or to decline to register
to vote, your right to privacy in
deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or
other political preference, you may file a complaint with the Secretary of State by calling toll-free
(800) 345-VOTE (8683)
or you may write to:
Secretary of State, 1500 - 11
th
Street, Sacramento, CA, 95814.
For more information on elections and
voting, please visit the Secretary of State’s website at www.sos.ca.gov.
Voter Registration Form
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APPLICATION FOR DSPS SERVICES (American River College)

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Completed 3 September 2020

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