Department of Supportive Programs and Services (DSPS)
2300 East Gibson Road, Building 700, Room 764, Woodland, CA 95776
Phone: (530) 661-5797 Fax: (530) 661-5788 Email: wccdsps@yccd.edu
Disability Verification and Consent Form
This section must be completed by the student:
________________________________ ___________________________ ___________________________
Students Last Name First Middle
________________________________ ___________________________ ________ _______________
Street Address City State ZIP
________________________________ ___________________________ ___________________________
Telephone DOB (MM/DD/YY) Student ID#
In order to receive disability-related services at Woodland Community College, a verification of disability must be provided.
I request that the professional designated below complete this form for the purpose of verification.
_____________________________________ _________________________ __________________________
Name of Licensed or Certified Professional Telephone Fax
_____________________________________ _________________________ ________ ______________
Street Address City State ZIP
Release of Information: I consent to the release of specific written and verbal information regarding my disability to
Woodland Community College, consistent with the Federal Family Educational Rights and Privacy Act (FERPA), or other
laws, regulations, or policies for use in educational planning. All information will be kept confidential and maintained as part
of my educational records with the DSPS department. I authorize the release of information to include the following records:
Diagnosis of disability signed by the appropriate medical practitioner or psychologist
Psychological testing and evaluation results
Detailed results of assessments or testing that led to diagnosis
Other ____________________________________________
I further give permission for DSPS specialists to discuss these records with other professionals at WCC who have a legitimate
educational need to know, and give permission for DSPS to forward records to other educational institutions per my request.
_______________________________ _______________ _______________________________ _______________
Student’s Signature Date Parent/Guardian’s Signature (if minor) Date
This section must be completed by the licensed or certified professional:
Please provide the following information in full to help determine reasonable educational accommodations to support this student.
1. Diagnosis: ______________________________________ Date of onset: _____________________________
2. DSM-V Code and Severity (if applicable): _______________________________________________________
3. Please describe how this condition limits or adversely impacts the students education or major life activities:
4. The condition is: Stable Prone to exacerbation
5. Duration of disability: Permanent/Chronic Temporary (Date expected to end:___________)
I understand that the information provided will become part of the students educational record, and may be released to the
student upon written request.
_______________________________ _______________ __________________________________________________
Verifying Professionals Signature Date Printed Name
Academic Year:____________ Summer Fall Spring
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