San Diego Community College District (SDCCD)
Disability Support Programs and Services (DSPS)
Application for Services
Today’s Date: Student ID Number:
Name: Date of Birth:
(PRINT) Last First MI
Address:
Street City State Zip
Telephone: E-mail:
Emergency Contact Person:
Relationship to Student: Telephone:
GENERAL INFORMATION
Have you applied to City, Mesa and/or Miramar College (admissions)? Yes No
Have you taken the College/CE Assessment/Placement Tests?
(If yes, include available scores)
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? Yes No If yes, where? Year:
Are you receiving services through? (check all that apply)
EOPS CalWorks WorkAbility III Financial Aid SSI/SSDI Veterans
Department of Rehabilitation Regional Center TRACE Other:
Counselor(s):
EDUCATIONAL HISTORY
Are you having academic difficulties? Please describe:
What is the highest level of education completed? (Check all that apply)
8 9 10 11 12 HS diploma GED Certificate of Completion
Highest college degree completed: Graduation date:
High school or other colleges attended:
Have you ever received Special Education/504/IEP/Resource/Remedial support? Yes No
If you are currently working, please describe employment:
Where?
