Fillable Application for Services (Woodland Community College)

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Application for Services (Woodland Community College)

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  • 8 check-boxes
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File type: PDF

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WOODLAND COMMUNITY COLLEGE
Department of Supportive Programs and Services (DSPS)
2300 East Gibson Road, Building 700, Room 764, Woodland, CA 95776
Phone: (530) 661-5797 Fax: (530) 661-5788 Email: wccdsps@yccd.edu
Application for Services
Please complete this form to apply for DSPS services.
_______________________ _______________________ _______________________
Last Name First Middle
_______________________ _______________________ _______ _____________
Street Address City State ZIP
_______________________ _______________________ _______________________
Home Phone Cell Work
_______________________ _______________________ _______________________
Email DOB (MM/DD/YY) Student ID
Disability:____________________________________________________________________________________
Please explain how your disability impacts your educational participation:
________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Were you referred to DSPS? ________ If so, by whom? __________________________________________
Are you a client of California Department of Rehabilitation? Yes No
Counselor’s Name: _____________________________ Telephone: ___________________________
Are you a client of Alta California Regional Center? Yes No
Counselor’s Name: _____________________________ Telephone: ___________________________
Are you a client of a private rehabilitation agency? Yes No
Counselor’s Name: _____________________________ Telephone: ___________________________
Do you receive assistance from any of the following? (Please check if you do.)
Financial Aid TRiO Veteran’s Services Department
EOP&S CalWorks
Academic Year:____________ Summer Fall Spring
Student Rights and Responsibilities
Participation in DSPS is entirely voluntary, and does not prevent a student from also participating in any
other course, program, or activity offered by Woodland Community College. All records maintained by
DSPS, relating to a student’s disability, shall be protected from disclosure, according to FERPA privacy
laws and CA Ed Code.
Students Have the Right to
1. Receive academic accommodations as documented in their DSPS Academic Accommodation
Plan (AAP) after the plan has been shared with an instructor.
2. File a complaint or appeal through the student grievances and appeals process if the student
believes he/she has been denied adequate or appropriate accommodations or has been
discriminated against on the basis of disability.
Students Do NOT Have the Right to
1. Receive a passing grade simply because they have an Academic Accommodation Plan (AAP) or
verified disability.
2. Receive accommodations that fundamentally alter the nature of a program, course, or activity.
Students Have the Responsibility to
1. Provide DSPS with the necessary information, documentation, and paperwork to verify the
student’s disability.
2. Meet with a DSPS professional to participate in an interactive process to determine the student’s
eligibility for DSPS and to develop a personalized Academic Accommodation Plan (AAP).
3. Complete and submit the paperwork required by DSPS relating to the student’s approved
accommodations.
4. Request accommodations from DSPS in a timely manner each semester and to provide
documentation of disability-related accommodations to instructors.
5. Make progress toward their educational goals, and utilize supportive resources (such as
supplemental instruction, tutoring, the RAWC, etc.) when needed.
6. Comply with the Student Code of Conduct for Woodland Community College.
7. Comply with the policies and rules established by DSPS.
I have read and agree to the above information, and I grant permission for information from this
application to be shared, on my behalf, with WCC personnel who are directly involved with the DSPS
program.
___________________________________ ___________________
Student’s Signature Date
___________________________________ ___________________
Printed Name Student ID
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Application for Services (Woodland Community College)

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Completed 25 July 2020

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