ACCESS Student Application Revised Friday, May 20, 2016 4:05 PM
Date Received:
Received by:
Full Name:
Student ID:
Full Address:
Home Phone:
Email:
Cell Phone:
Date of Birth:
Copper Mountain College provides a variety of programs and educational services which afford eligible students 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 ACCESS for students with disabilities.
Section 1: Please check all that apply to you:
Acquired Brain Injury
Deaf/Hard of Hearing
Mental Health Disability
ADHD
Intellectual Disability
Other Health Condition
Autism Spectrum
Learning Disability
Physical Disability
Blind/Low Vision
Section 2: This section is for students who received specific services in school. If this section does not apply,
please go to Section 3. Verification from school is required.
City, State:
What special education services did you receive in the past:
Resource Specialist Program (RSP)
Special Day Class (SDC)
Transition Program (TPP)
IEP
504
If tested for a learning disability, where were you tested?
Section 3: This section is for verification from a medical professional.
Dr. Name:
Phone No.
City, State:
Fax No.
Section 4: Check the descriptions that best describe how your impairment affects you.
Reading
Vision
Test-taking
Writing
Hearing
Note-taking
Math
Health/Physical
Section 5: Check all that apply if you are currently receiving these services:
Department of Rehabilitation
Inland Regional Center
Veteran’s Services
I understand that participation in ACCESS is strictly voluntary. Your signature denotes application for services
and consent to release relevant information to instructors.
Student Signature
Date
Signature of Parent or Guardian (if under 18)
Date
Copper Mountain College
ACCESS Student Application
The Copper Mountain Community College School District complies with all State and Federal regulations and does not discriminate on the basis of race, color, national origin, gender or
disability. This holds true for all district employment and opportunities. Harassment of any employee or student with regard to race, color, national origin, gender, or disability is strictly
forbidden. Inquiries regarding compliance and/or grievance procedures may be directed to the school district’s Title IX Officer and/or Section 504/ADA Coordinator. For the Title IX
Officer and/or 504/ADA Coordinator contact the Human Resource Office, 6162 Rotary Way, Joshua Tree, CA 92252 (760) 366-5267.
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