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?
Distribution: Disability Support Program and Services (DSPS)
SS-DSPSAPS 01/2018
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.
Student Signature: Date:
OFFICIAL USE ONLY
Received by: Date:
click to sign
signature
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