Name: Student ID#:
Application for Temporary Services
Address:
Home Phone#: Cell#
E-Mail DOB
Disability Support Services (DSS)
Date
Are you currently enrolled at DVC?
Yes No
Yes No
Do you have documentation verifying your temporary disability?
Have you submitted your documentation to DSS office?
Yes No
Services I am requestiong:
Mobility - Laurence Orme (SSC 248) 925-969-2173
Note Taking - Rachel DeChristofaro (SSC 248) 925-969-2178
In-Class Aide - Lawrence Punsalang (SSC 248) 925-969-2182
Alternate Media - Rose Desmond (SSC 248) 925-969-2174
Testing - Ron Tenty (SSC 248) 925-969-2185
Student Responsibilities
1. I will provide DVC's Disability Support Services (DSS) program with the information, documentation,
and /or forms (medical, educational, etc.) necessary to verify my my disability.
2. If my temporary disability condition presets, worsens,or elevates to a permanent diagnosis, I understand that
I must see a DSS Counselor and submit complete and current documentation of my condition..
3. I will meet with DSS Faculty or Staff personnel to compete a Student Educational Contract.
4. I will use the DSS program in a responsible manner.
5. I will comply wiht the Student Code of Conduct adopted by SRJC.
With this application I request services from the DVC's DSS program. I have read the Student
Responsibilities and agree to participate. I understand there are Grievance Procedures, posted on the
college website that I can follow should I disagree with decisions about my disability related services.
I understand that this is a temporary accommodations will expire when services are no longer needed.
