SAN DIEGO COMMUNITY COLLEGE DISTRICT (SDCCD)
Disability Support Programs and Services (DSPS)
Application for Services
G:\data\share\dsps\Forms\ApplicationPaperwork\Application for Services 06-01-12.doc
TODAY’S DATE: __________________ CSID: ______________________
Last Name:_________________________________ First Name: __________________________________ MI:___________
Address:_______________________________ City, State and Zip:_______________________________________________
DOB:_____________________ Home Phone:________________________ Cell Phone: __________________________
E-mail Address: __________________________________________________________________
Emergency Contact Person________________________________________________________
Relationship to Student: : _________________________________ Phone:
GENERAL INFORMATION
Have you applied to City, Mesa, Miramar College(s) (Admissions)? Yes _____ No _____
Have you taken the College/CE Assessment/Placement Tests? (if yes, include scores if available)
MATH: No____Yes_________________ ENGLISH: No____Yes_________________ ESL: No____Yes_________________
DEAF ENGLISH: No____Yes_________________ TABE: No____Yes_________________
What is your current educational goal (if known)? ____________________________________________________________
Would you like assistance with Voter Registration? Yes____ No____
Have you ever received services from any SDCCD DSPS Office? No____ Yes____ Year_______ Where? ______________
Are you receiving services through? (check all that apply)
____EOPS ____Cal WORKS ____WorkAbility III ____Financial Aid ____SSI/SSDI ____Veterans
____Department of Rehabilitation ____Regional Center ____TRACE ____Other (list here) _________________
Counselor(s):___________________________________________________________________________________________
EDUCATIONAL HISTORY
Are you having academic difficulties? (describe)_______________________________________________________________
What is the highest level of education completed? (Check all that apply)
8 9 10 11 12 HS diploma GED Cert. of Completion
Highest college degree completed_____________________________________Graduation Date: ______________________
High School or other Colleges attended: _____________________________________________________________________
Have you ever received Special Ed./504/IEP/Resource/Remedial support? Yes ____ No ____
If you are currently working, please describe employment:
Where? _________________________________________________________________________________________
SAN DIEGO COMMUNITY COLLEGE DISTRICT (SDCCD)
Disability Support Programs and Services (DSPS)
Application for Services
G:\data\share\dsps\Forms\ApplicationPaperwork\Application for Services 06-01-12.doc
DISABILITY INFORMATION
Please respond to all by checking yes or no
Yes
No
Yes
No
Acquired Brain Injury
Psychological Disability
Brain Tumor
History of mental health problems
Stroke
History of Substance Abuse
Traumatic head injury
Inpatient/Outpatient Counseling
Hearing Loss
Other Disabilities
Deaf
Aids/ HIV
Hard-of-hearing
Attention Deficit Disorder (ADD or ADHD)
Use Sign Language
Autism/ Asperger Syndrome
Cochlear implant/ Hearing aid
Cystic Fibrosis
Mobility
Diabetes
Epilepsy/ Seizures
Amputation
Gastrointestinal Disorder
Arthritis
Hemophilia
Cerebral Palsy
Immune System Disorder
Multiple Sclerosis
Other Health: ___________________________
Orthopedic
Post Polio
Learning Disability (LD)
Respiratory
Spinal Cord Injury
Requesting first time LD testing
Other: ___________________________
LD has been verified by a:
High School
Speech / Language Disability
University
CA Community College
Aphasia
Other: ___________________________
Dysarthria
Dysfluency
DDL/Intellectual Disability
Other:
Visual Disability
It is the responsibility of the student seeking accommodations and services to provide a comprehensive evaluation verifying the
disabling condition(s) and the resulting educational limitations.
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