APPLICATION TO REQUEST DISABILITY SUPPORT SERVICES
Name
Last First M SWC ID #
Address
Street City State Zip Code
Phone
Mobile/Home To Receive Texts Confidential (for leaving private messages)
Birthdate College eMail
Emergency Contact Emergency Contact Phone
Southwestern College provides support services, through the Disability Support Services (DSS) Office,
for eligible students with documented disabilities who intend to pursue coursework at SWC.
Completion of this form constitutes an agreement to apply for DSS. Please complete the following and
return to the DSS Office, Room 68-108, in the Student Services Center.
Please check any disabilities that may apply to you:
Acquired Brain Injury
ADHD
Autism Spectrum
Deaf/Hard of Hearing
Intellectual Disability
Learning Disability
Mental Health
Mobility
Speech / Language
Visual Impairment
Other Conditions:
At what age did your disability occur?
How does your disability impact your learning?
Please list any academic accommodations previously received:
Have you received Special Education Services in the past?
Resource Specialist Program (RSP) Special Day Class (SDC) Speech/Language Therapy
Are you a client of any of the following agencies?
Department of Rehabilitation Regional Center County Mental Health
Have you applied for or are you currently participating in any of the following programs?
Financial Aid
EOPS
Are you a veteran? Yes No
Student Responsibilities
1. I will provide DSS with recent written documentation (medical, educational, etc.) that verifies
my disability.
2. I will meet with a DSS professional to discuss my progress each semester.
3. I will follow the DSS Service Policy.
My signature certifies the application information is true. I understand the three student responsibilities.
Applicant’s Signature DATE
I acknowledge receipt of voter registration information in compliance with the National Voter
Registration Act.
To request this material in alternate media, please call voice (619) 482-6512 or VP (619) 207-4480.
Office Use: Date Received: Initials:
Once your application and verification have been processed, please know that it
can take up to two weeks for you to be scheduled for an eligibility appointment.
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