Fillable Application For Services (Las Positas College)

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Application For Services (Las Positas College)

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The Application For Services (Las Positas College) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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DisabledStudentPrograms&Services

3000CampusHillDrive|Room1615,Livermore,CA94551

(L):DSPSData|NewForms|FinalDrafts_6.4.19

APPLICATION FOR SERVICES

LastName

: FirstName:

W#: DateofBirth: Gende

r:

MailingAddress:

City:

 State: ZipCode:

Phone:

 E‐mail:

 AreyourequestingDSPSservicesfora short‐terminjury? Yes

No

Pleaseprovidedocumentationfortheshort‐termdisabilityifavailable.

 AreyouaDepartmentofRehabilitationclient? Yes No

 Areyou(orhaveyoueverbeen)aRegionalCenterClient? Yes No

Brieflyexplainwh

yyouarerequestingservicesthroughtheDisabledStudentProgramsand

Servicesdepartment:

____________________________________________________________________________

____________________________________________________________________________

ForOfficeUseOnly

AcquiredBrainInjury(ABI)

AttentionDeficitHyperactivityDisorder(ADHD)

AutismSpectrum

Blind/LowVision

Deaf/HardofHearing(DHH)

IntellectualDisability(ID)

LearningDisability(LD)

MentalHealthDisability

PhysicalDisability

OtherHealthCondition/Disability

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Completed 26 July 2020

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