If you require this form in an alternative format, please contact SAS at (408) 288-3746, or email sjcc.sas@sjcc.edu.
STUDENT ACCESSIBILITY SERVICES
2100 Moorpark Avenue, San Jose, CA 95128-2799
Phone: 408-288-3746
Fax: 408-971-8201
Email: sjcc.sas@sjcc.edu
Application for Services
CONTINUE ON THE NEXT PAGE
Page 1 of 2
Date: __________________
General information
Student ID#:
Name:
Last First Middle Initials
Address:
Number
Street
City
State
Zip Code
Cell Phone #:
Secondary Phone #:
Email:
Person to be notified in case of emergency
Name:
Relationship to Student:
Last First
Contact #:
Secondary Contact #:
Disability Information -Please check all disabilities with which you have been diagnosed
ADD/ADHD
Mental Health
Autism/Asperger
Mobility
Blind/Low Vision
Speech
Acquired Brian Injury (TBI)
Temporary Disability (Describe):___________________
Deaf/Hard of Hearing
Intellectual Disabilities/ DDL
Other: ________________________________________
Learning Disability (from IEP or LD Assessment)
I feel I have a learning disability and would like testing.
How does this disability(ies) affect your school related activities?
Please check all accommodations/services you may require:
General Accommodations
Note Taker
Adjustable Table/ Ergonomic Chair
Preferential Seating:
Specialized Instruction
Specialized classes
Tutoring
Alternate Format
E-Text
Enlarged Print
Braille
Audio
Deaf/HoH Services
ASL Interpreter
Real time captioner
Testing Services
Extended Testing Time
Assistive Technology
Briefly explain any additional information about the accommodations/services you may require (optional):
If you require this form in an alternative format, please contact SAS at (408) 288-3746, or email sjcc.sas@sjcc.edu.
Application for Services
Submit this application form along with your verification of disability to the SAS Office
Page 2 of 2
What is your academic/ vocational goals?
Transfer to a 4 year university/college
AS/AA Degree
Certificate/ Vocational
Basic Skills
ESL
Other:__________________________
Major/Interest:
Check other SJCC programs you receive services from:
Athletics
EOPS
Veterans
Other:__________________________
CalWorks
METAS
Not Applicable
Check community programs you receive services from:
San Andreas Regional Center
Other: _____________________
Year:
Yes No
Yes No
Department of Rehabilitation Post-secondary program
Greater Tomorrow Lights of Hope
First Community Program Contact (Skip if this is not applicable to you)
Name of Program:
Case worker/Counselor Name:
Contact Number:
Email:
Secondary Community Program Contact (Skip if this is not applicable to you)
Name of Program:
Case worker/Counselor Name:
Contact Number:
Email:
Educational History
What year did you graduate/will graduate from high school?
Have you ever received Special Ed/504/IEP Resource/Remedial support?
Do you have transcripts from other colleges/universities?
Have you ever been registered with a DSPS/SAS office at another college?
Yes No
If YES, please provide the name of the college.
College:
Employment
Are you currently working?
Yes No
If no, skip the following questions
What is your occupation?
How many hours per week are you working?
Hours
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