DSPS Student Record Forms (intake packet)
Please use pen to fill out forms
There are eight forms in our current DSPS intake packet:
Our forms are also on the CCDSPS website and available in Alternate format upon request.
Revised: 6/29/16 KR/CH
Know Your Rights and Responsibilities Acknowledgement (pink sheet) - This acknowledgement needs to be
read, understood and discussed with the DSPS Coordinator and/or Counselor. It is available in alternate format
upon request. Prior to your intake appointment, please read over the Know Your Rights and Responsibilities
Acknowledgement. You will discuss its contents and sign the digital form with certificated staff during a
scheduled appointment. (Title 5-Section 56008, Student Rights)
Application for DSPS services - This required form is a signed application for services and verification of
enrollment in the college. This form will be reviewed during your intake appointment. You are required to
complete a DSPS application acknowledging responsibility to provide appropriate verification of disability. (Title 5-
Section 56002, Student with a Disability)
Verification of Disability Status and Identification of Educational Limitations - You are required to submit
documentation of your disability. This disability documentation can be provided by a professional who is qualified
to make the specific diagnosis and is unrelated to you: an M.D., licensed psychiatrist, clinical psychologist, speech
pathologist, audiologist, LD Specialist, a Marriage, Family and Child (MFC) Counselor, or licensed Clinical Social
Worker. (Title 5-Section 56006, Determination of Eligibility)
Consent for Release of Information - A signed release of information enables the college to verify the disability
or obtain other types of records. You must sign this form and, with your permission, this form then can be used
by DSPS to obtain disability verification and/or to exchange disability related information with college personnel
who have a “legitimate educational need to know.” This form also allows information to be shared among DSPS
staff. (Title 5-Section 56008, Student Rights)
Instructor Consent/Permission - This form gives DSPS your consent to contact instructors and/or exchange
disability related information. For example, requests for test facilitation or intervention with learning strategies.
(Title 5-Section 56008, Student Rights)
Family Educational Rights and Privacy Act (FERPA) Consent for Release - This form should be signed by
individuals under 18 years of age to protect the privacy of their student educational records and/or prior to DSPS
staff speaking to a parent/third party on the telephone. (20 U.S.C.§ 1232g; 34CFR Part 99.)
Overview of Disabled Students Programs and Services (for information/discussion only) - This document
contains information regarding current academic adjustments, auxiliary aids, services and/or instruction
offered through DSPS.
High School to College Transition Guide (for information/discussion only) - This transition guide addresses
topics that may be confusing due to the differences in college accommodations. It includes discussion contrasting
the mandated services in K-12 system to those available in the college setting, illustrating the self-advocacy role
that you need to assume when you attend college. Additionally, it addresses the status as “adult” at age 18 which
shifts the responsibility for decisions from the parent to you.
