Fillable MERRITT COLLEGE Application Student Accessibility Services R-109 (510) (Merritt College)

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MERRITT COLLEGE Application Student Accessibility Services R-109 (510) (Merritt College)

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9 8 14
MERRITT COLLEGE
Application
Student Accessibility Services
R-109 – (510) 436-2429
Merritt College provides support services for students with verified
disabilities through the Student Accessibility Services (SAS).
Completion of this form constitutes an agreement to apply for SAS
Services.
Last Name, First Name
Student ID Number
Date of Birth
Address
City
Zip Code
Phone:
Alt. Phone:
Email
Emergency
Contact
Major/Educational Goal:_______________________
□Transfer □AA/AS Degree □Certificate □Basic Skills
□ Career/Technical Education □Other____________________________
Disability____________________________
How does your disability affect your school work?________________
_________________________________________________________
Prior Accommodations and Services Received: □Yes □No
□Special Classes in High School □Speech/Language □ IEP
□Other___________________________________________________
Are you a client of:
□ State Department of Rehabilitation___________________________
□ Regional Center__________________________________________
□ County Mental Health______________________________________
□ Veterans Administration____________________________________
STUDENT RESPONSIBILITIES:
1. Provide SAS with recent written verification (Medical, Educational, etc.) of disability
2. Meet at least twice per semester with a SAS Counselor
3. Follow SAS Policies and Procedures
4. Comply with Student Conduct Standards found in the College Catalog.
My signature certifies the application information is true. I understand the four
responsibilities to participate in the SAS program. I understand the Rights and
Responsibilities are in the SAS Student Handbook.
Signature______________________________ Date________________
9 8 14
1
MERRITT COLLEGE
Student Accessibility Services
12500 Campus Drive
Oakland, CA 94619
(510) 436-2429
Consent for Release of Information
Name: _____________________________ Birth Date: ___________
Former/Other name: ________________ Student I.D. #___________
I, the undersigned, request any appropriate person and/or agency or institution to
release information consistent with the federal Family Education and Right to Privacy
Act (FERPA, 1974) or other laws, regulations, or policies to this college for use in
educational and vocational planning. All information will be kept confidential and
maintained as a part of my records with the SAS office. Selected information may be
released for mandated state and/or federal reports. I authorize the release of
information that may include one or more of the following records:
____ Medical data verifying disability and/or head injury and functional limitations
(Please complete & return enclosed form)
____ Psychological testing and evaluation results
____ Learning Disabilities Eligibility documentation
____ Vocational rehabilitation plan
____ Educational records, transcripts (including progress made)
____ Recent speech pathology or neuropsychological evaluation & discharge summary
____ Recent audio logical and eye exam reports
____ Other: ____________________________________________________________
I further give permission for SAS certificated staff to discuss my educational situation with (check)
___faculty ___counselors ___doctors ___family member: _____________________
___Health Center Certificated staff ___other:_____________________________
This authorization shall remain in effect until revocation in writing has been received by Merritt College,
Student Accessibility Services.
_________________________________________ ____________________
Signature Date
_________________________________________ _____________________
Parent/Guardian signature (if student is under 18) Date
A photocopy of this is as valid as the original
9 8 14
MERRITT COLLEGE DISABILITY VERIFICATION FORM
Counselor:________________________________ Please return to DSP via FAX 510-434-3888
Student Accessibility Services
12500 Campus Drive, Oakland, CA 94619 Phone: (510) 436-2429
THIS SECTION MUST BE COMPLETED BY THE STUDENT:
Name:___________________________________________________________*SSN/ID#:________________________
Address:_________________________________________________________________________________________
Birth Date: / / __ TELEPHONE:(________)_____________ email: ________________________________
Mo/day/year (area code)
In order to receive disability-related services a verification of disability must be provided. I request that the professional
designated below complete this form.
Student Signature:______________________________________Date: _______________________
Name of Licensed or Certified Professional:__________________________________________________________________
Address:_______________________________________________________________________________________________
FAX #:__________________________________________________TELEPHONE #:__________________________________
THIS SECTION MUST BE COMPLETED BY THE LICENSED OR CERTIFIED PROFESSIONAL:
Please provide the following information in full in order to help determine reasonable educational accommodations to support
this student:
1. Diagnosis:
2. DSM IV Code and Severity (if applicable)
3. Please describe how this condition substantially limits major life activities:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4. Condition is: stable prone to exacerbation
5. Duration of Disability: Permanent/Chronic Temporary (date of re-evaluation or estimated duration of
disability)_________________________
Educational, medical, and/or psychological documentation should be attached and returned to the address above.
3
MERRITT COLLEGE
Student Accessibility Services (SAS)
YOUR RIGHTS AND RESPONSIBILITIES
Students with disabilities have the right to expect:
• Full and equal participation in the services and activities in Merritt Community
College and SAS
• Reasonable accommodations, academic adjustments and/or auxiliary aids and
services in response to documented disabilities.
• Confidential information about their disability will not be shared without their
prior consent unless permitted by law and only on a “need-to-know” basis.
• Limited access to anecdotal information maintained by SAS.
• Information about SAS Policies, procedures, accommodations, and services will
be readily available in alternate formats upon timely request.
• You have the right to appeal.
POLICY GUIDELINES FOR SERVICES, ACCOMMODATIONS, & ACADEMIC ADJUSTMENTS
As required by Title V of the California Education Code, the following policy has been
adopted by the Student Accessibility Services program at Merritt College. Services
are provided to enrolled students who apply, provide verification of disability and
meet Merritt College admissions, matriculation and conduct requirements. Services,
auxiliary aids and academic adjustments are designed to facilitate the success of
students in reaching their individual educational/vocational goals.
A. STUDENTS’ RESPONSIBILITIES FOR SUPPORT SERVICES
1. Students will provide SAS with the necessary information, documentation
and/or forms (medical, education, etc.) to verify disability.
2. Students must comply with the Merritt College “Rules for Student
Conduct” at all times (see current college catalog.)
3. Students must request support services from their SAS Counselor every
semester. Support services are based on the students’ schedule of classes,
SAS Annual Contract, and documented disability.
4. Students are responsible for providing an updated verification of disability,
if requested, by their SAS Counselor.
5. Early registration is encouraged to ensure availability of classes and to be
able to request support services in advance. Every effort is made to provide
needed services, however, due to limited resources, late registrants will
receive lower priority and may not receive some support services.
6. Students must obtain the books and supplies required for the courses in
which they are enrolled in order to qualify for support services.
7. Students are responsible for notifying their SAS Counselor when a support
services provider resigns or fails to meet with the student.*
8. Students are expected to notify their services providers when they are
unable to keep a meeting with them.
*If you experience any difficulties with any service provider or SAS
Employee, such as, inappropriate, irresponsible or harassing behavior of
any kind, report it immediately to your SAS Counselor or the SAS
Coordinator.
B. PROGRESS REQUIRED
Students are required to make measurable progress toward their chosen academic
or vocational goal by enrolling in classes outlined in their Student Educational
Plan. Progress is evidenced by obtaining a “C” or better grade (no “I”, “IP” or “W”
grades) for the majority of courses each semester.
C. ACCOMODATION PROCEDURES
SAS Counselors approve academic accommodations and/or support services for
students. Students provide a copy of the Accommodation Notice to the instructor.
If an instructor who is given an Accommodation Notice refuses to provide or
arrange to have provided, the necessary accommodations, students are advised to
notify their SAS Counselor immediately for assistance in resolving the matter.
D. POLICY FOR SUSPENSION OF SERVICES
Failure to comply with the responsibilities as outlined above may result in
suspension of services. Students will be informed in writing including appeal
procedures.
E. REINSTATEMENT OF SERVICES
Criteria for reinstatement of services will be determined on an individual basis
following a meeting with the SAS Counselor or SAS Coordinator, as appropriate,
and a written copy of the criteria will be given to the student. Appeals may be
directed to the SAS Coordinator. If needed, further appeal may be made to the
Vice President of Student Services and then, if desired, to the Merritt College
Grievance Committee.
F. STUDENT CONTRACT
I have read the policy, rights, and guidelines of this form and understand them. I
agree to meet my responsibilities as outlined in these guidelines.
________________________________ _____________
Student Signature Date
________________________________ _____________
SAS Counselor Signature Date
C:\policy guidelines for services, accommodations, and academic adj 1 07012012 revised 6/5/2013 bd
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MERRITT COLLEGE Application Student Accessibility Services R-109 (510) (Merritt College)

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Completed 2 February 2021

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