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DSPSApplication Pasadena city college DSPS Application

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Pasadena City College
Disabled Student Programs and Services
Application For Services
Date: _________
First Name: M.I. Last Name:
Lancerpoint ID: Date Of Birth (optional): ____________
Address:
C
ity: State: Zip:
Primary Phone □Cell □Home □Video Phone
Secondary Phone □Cell □Home □Video Phone
Lancerpoint email: @go.pasadena.edu
Alternate email:
DSP&S Background
You are requesting accommodations for: □ Spring □ Summer □ Fall □ Winter
Do you need immediate accommodations for a class in which you are currently enrolled: □Yes □No
The Accommodation I need is:
Have You Attended College/University Before? □Yes □No
Which Colleges/Universities?
Have you used disability services before? □Yes □No
Which College? Year:
Accommodations Received:
Educational Information and Goals
What Is Your Long-Term Educational Goal
What are your academic goals At PCC? □ AA/AS □ Transfer □ Certificate □ Job Skills
□ Personal Enrichment □ Other (Please Explain):
What is your long-term educational or Career Goal(s)?
Off-Campus Support
□ Department of Rehabilitation □ Regional Center □ Veteran’s Affairs
□ Department of Mental Health □ SSI □ SSDI □ TANF
□ Other:
Name of Contact:
Telephone/Email:
PASADENA CITY COLLEGE |W:pccshare/dsps15-16
__________________________________________
__________________________________________
__________________________________________
On-Campus Support Services
Who referred you to DSP&S at PCC?
Do you use any of these On-Campus Services:
□ EOP&S □ CARE □ Foster Youth □ Calworks □ PASS □ Pathways
□ Veteran’s Resource Center (VRC) □ The Zone □ Other:
Have you applied for: □ Financial Aid □ BOGG Fee Waiver
Are you involved in any on-campus clubs or organizations? □Yes □No
Please Describe:
Health and disability information
Check all disabilities that apply:
□ Acquired Brain Injury/TBI □ Intellectual Disabilities □ PTSD
□ Autism Spectrum Disorder □ Learning Disability □ Seizure Disorder/Epilepsy
□ ADD/ADHD □ Mental Health Disability □ Speech/Language Impairment
□ Deaf or Hard Of Hearing □ Physical Disability □ Blind/Visually Impaired
□ Other (Please Describe):
Additional Information:
Do you need help evacuating in case of an emergency? □Yes □No
Other Concerns
Privacy information
*The Community College District uses the information requested on this form 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 recorded on this form 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.
I am requesting DSPS services related to the educational process at PCC. I understand that DSPS services will not be provided
until I submit verification of disability and meet with a DSPS Professional to determine reasonable accommodations.
Student Signature________________________________ Date
Date and Time of Appointment (Office Use Only)
PASADENA CITY COLLEGE |W:pccshare/dsps15-16
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Completed 3 November 2019

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