Revised 06/01/2018
Disabled Students Programs & Services
APPLICATION FOR SUPPORT SERVICES
DSPS keeps a confidential file of your submitted documents. To make sure your file is available for
your appointments with your DSPS counselor, please tell us which campus will you be scheduling your
appointments at?
San Jacinto (SJC) Menifee (MVC) Temecula (TEC) Banning (SGP)
Student ID #: ____________________
Students Name: _____________________________________________________
First Middle Initial Last
Address: __________________________________________________________
Street Number Street Name Apt. # City Zip
Phone #: (_____) ______________ Student Em
ail: _______________________@student.msjc.edu
Please check any verified disabilities that may apply to you:
Visual Impairment Deaf/Hard of Hearing Brain Injury
Learning Disability Mobility/Physical Mental Health
Intellectually Delayed ADHD Autism Spectrum
Other: __________________________________________
How does your disability impact your ability to learn? _________________________
Are you a client of any of the following agencies?
Department of Rehabilitation Regional Center VA Rehab
City: __________________
Emergency Contact: ________________________________________________________________
Name Relationship Phone #
Current Medications (please include dosages): ___________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please note: Submission of an application does not mean you will be eligible for services
Student Signature: ______________________________ Date: __________________
DSPS Staff Signature: __________________________ Date: __________________
Student does not qualify for services (make copy for the student)
Reason: ___
Date of Birth: __________________
Revised 06/01/2018
Disabled Students Programs & Services
STUDENT RIGHTS AND RESPONSIBILITIES
Student’s Last Name
First Name Middle
Date of Birth
Student ID#
Disabl
ed Student Programs & Services (DSPS) receives special funding to provide
services to students with disabilities and is required to meet state and federal
regulations.
To help you comply with these regulations, you, as a student receiving DSPS services,
have the following rights & responsibilities:
RIGHTS
My participation in DSPS is voluntary
As a qualified student with a verified disability, I have the right to receive
reasonable academic accommodations based on my educational limitations in
order to have access to activities, programs, and services
I sh
all not be discriminated against in any way on the basis of my disability
All of my records maintained by DSPS will be kept confidential
RESPONSIBILITIES
I will provide DSPS with verification of my disability
I will meet with a DSPS Professional or Counselor to update my DSPS file once
every academic year
I will make progress toward my academic goals outlined in my Educational Plan
I will notify DSPS in advance if I am unable to attend scheduled appointments
I will return any equipment on loan from DSPS at the end of each semester
I will maintain appropriate behavior in the educational setting and abide by AP
5500 Standards of Student Conduct
I will be responsible in my use of DSPS services and adhere to written service
policies adopted by DSPS
Student Signature: ________________________________ Date: _____________
DSPS Staff Si
gnature: _______________________________ Date: _____________
Authorities cited: Education Code Section 66300 and 66301; Accreditation Standards I.C.8 and 10
Date: __________________
Disabled Students Programs & Services
PRIVATE INFORMATION CONSENT FORM
Notice: A photocopy of this signed form is as valid as the original.
Student’s Last Name
First
N
ame
Date o
f Birth
Student ID#
____
Initial
I provided the Disabled Students Program & Services (DSPS) with copies of school and/or
medical records containing information regarding my disability in order to receive disability
support services at Mt. San Jacinto College.
I hereby authorize DSPS to discuss my educational situation with the following personal individual(s):
Name: ____________________________________ Relationship: _______________________________________
Nam
e:
____________________________________ Relationship:
_________________________________
______
By signing this document, I understand my rights to privacy, and herby authorize the Mt. San Jacinto
College District - Disabled Students Program & Services to discuss my private information with any
approved personnel so long as a legitimate need exisits.
Student Signature: ___________________________________
Date: _________________
Signature of Parent or Guardian: __________________________ Date: __________________
(Required for Students Under 18 Years of Age)
DSPS Staff Signature: __________________________________
*The Mt. San Jacinto Community College District uses the information requested in this packet for the purpose of determining a student’s eligibility to
receive authorized special services provided by the Disabled Students Programs and Services (DSP&S) Program. Personal information provided to the
DSP&S program will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the
Chancellor’s Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict
accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232 (g)). The
information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of
Regulations, Title 5, Section 56000 et seq.
Privacy Information:
____
I give permission for DSPS staff members to discuss my educational progress or the lack
of with other professionals who may have a legitimate educational need to know. This
shall remain in effect during my enrollment at MSJC or until revoked in writing.
Initial
Revised 06/01/2018
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