Fillable Application to Request Disability Support Services (Crafton Hills College)

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Application to Request Disability Support Services (Crafton Hills College)

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Crafton Center (CCR) 101 (909)389-3325 chc_dsps@craftonhills.edu
www.craftonhills.edu/current-students/disabled-student-services
Disabled Students Programs and Services (DSPS)
Application to Request Disability Support Services
DSPS Program Overview: Crafton Hills College provides educational services and access for eligible students with
documented disabilities who intend to pursue coursework at the college. A variety of programs and services are available which
afford eligible students with disabilities the opportunity to participate fully in all aspects of college programs and activities through
appropriate and reasonable accommodations. Completion of this form constitutes an agreement to apply for Disabled Student
Programs & Services (DSPS). Please complete the following and return to the DSPS office. Completion of this form does not imply
acceptance into the DSPS program.
Student Information
Name:
Last First Middle
Student ID: _________________________
Mailing Address:
P.O. Box/Street City/State Zip Code
Primary
Phone
Number:
______________________________
Birth
Date: ____________Gender: _______
Disability Information
In order to provide academic accommodations that will support your educational goal, please tell us about your disability below:
Disability: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Briefly explain the accommodations you may require: _____________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Educationally-related side effects of medications (if any): __________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Educational History
Have experienced any of the following during your school experience:
□ Special Education Classes □ Being passed without Learning □ Learning Disability Assessment
□ Repeating grades □ Dropping Out □ Academic Accommodations at Another College/University
Describe:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Disabled Students Programs and Services (DSPS)
Crafton Center (CCR) 101
(909)389-3325
chc_dsps@craftonhills.edu
www.craftonhills.edu/current-students/disabled-student-services
On Campus Resources
Have you ever applied for or are you currently participating in any of the following programs?
□ EOPS □ CARE □ Financial Aid □ CalWORKs □ Promise
Current Status:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Off Campus Agencies
Have you received services from the following agencies:
□
Department of Rehabilitation - Counselor: ___________________________________________________
□
Inland Regional Center- Counselor: _________________________________________________________
□
County Behavioral Health- Therapist/Psychiatrist: _____________________________________________
□
Veteran’s Administration – Therapist/Physician:_______________________________________________
Current Status:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
My Signature indicates I the information that I provided on this application is true. It also indicates that I have reviewed and understand the
Crafton Hills Rights and Responsibilities and received a copy.
Signature of Applicant Date
Note: you will be notified of the determination of your request for services after the DSPS office has received documentation regarding your disability.
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Application to Request Disability Support Services (Crafton Hills College)

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Completed 4 September 2020

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