Mission College provides educational services and access for eligible students with documented disabilities who intend to pursue
coursework at Mission College. A variety of programs and services are available which afford eligible students with disabilities the
opportunity to participate fully in all aspects of college programs and activities through appropriate and reasonable accommodations.
Completion of this form constitutes an agreement to apply for Disability Instructional Support Center Services (DISC).
Student Responsibilities:
1. I will provide the DISC with the information, documentation and/or forms (medical, educational, etc.) deemed necessary by DISC
to verify my disability(ies).
2. I will meet with a DISC professional to complete a Student Educational Contract, and agree to meet with the professional at least
annually to update the Student Educational Contract.
3. I will utilize the DISC in a responsible manner. I understand that the DISC uses written service provision policies and procedures
that must be adhered to for continuation of services.
4. I will comply with the Student Code of Conduct adopted by the college.
I understand that I must fulfill the requirements for participation in the DISC Program. I have received a copy of the policy on suspension of DISC
services, and I understand the consequences of failing to comply with the rules for responsible use of DISC services. I understand that I will be
notified in writing before any action is taken to suspend services. By signing this application I affirm that I understand and agree with the DISC
Program responsibilities of students and I will abide by them.
DISC Specialist Signature Date
Student Signature Date
The 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 Disabled Students Programs and Services (DSP&S) Program. 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 applicable statutes regarding confidentiality, including the Family Educational Rights and
Privacy Act (20 U.S.C. 1232 (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 56000 et seq.
FOR USE BY DISC PERSONNEL ONLY
Application Processed by:
Summer Fall Spring
Comments:
