ACCESS Student Application Revised Friday, May 20, 2016 4:05 PM
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:
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.
What special education services did you receive in the past:
Resource Specialist Program (RSP)
If tested for a learning disability, where were you tested?
Section 3: This section is for verification from a medical professional.
Section 4: Check the descriptions that best describe how your impairment affects you.
Section 5: Check all that apply if you are currently receiving these services:
Department of Rehabilitation
I understand that participation in ACCESS is strictly voluntary. Your signature denotes application for services
and consent to release relevant information to instructors.
Signature of Parent or Guardian (if under 18)
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.