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MODESTO JUNIOR COLLEGE DISABILITY SERVICES & PROGRAMS FOR (Modesto Junior College)

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Rev. 3/10/20
MODESTO JUNIOR COLLEGE
DISABILITY SERVICES & PROGRAMS FOR STUDENTS (DSPS)
435 College Ave.
Modesto CA 95350
(209) 575-6225
mjcdsps@mjc.edu
Student Application for Services
Name: ☐ Male ☐ Female
(Print) LAST FIRST MI
Address:
Mailing Address City State Zip
Home Phone #: Cell Phone #: Work #:
DOB: AGE:
MJC Student ID#: MJC Student Email:
Last High School Attended: Year of Graduation:
If you are still in high school Current grade
New ☐ Returning ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Phone:
Yes ☐ No ☐
1. Are you a new or returning student? (Check one)
2. Do you have a current MJC admissions application on file?
3. Have you used the GPA or the self-guided placement tools?
4. Have you completed the MJC orientation?
5. Have you completed an educational plan?
6. Have you received disability services from another college?
Name and location:
7. Are you a client of the Department of Rehabilitation?
If yes, counselor’s name:
8. Are you a client of Valley Mountain Regional Center?
If yes, case worker’s name:
Phone:
====================================================================
* FOR OFFICE USE * Application Received
Acquired Brain Injury Intellectual Disability Deaf and Hard of Hearing
Learning Disability Physical Disability Mental Health Disability
Blind and Low Vision Autism Spectrum Other Disabilities
Attention-Deficit Hyperactivity Disorder Counselor
Approval__________________
Orientation- Y N Testing- Y N Ed Plan- Y N Enrolled –Y N
Rev. 3/10/20
MODESTO JUNIOR COLLEGE
DISABILITY SERVICES & PROGRAMS FOR STUDENTS
Student Requirements and Responsibilities Statement
PROGRAM OVERVIEW:
Modesto Junior College (MJC) provides educational services and access for eligible students with
documented disabilities who intend to pursue coursework at the college. A variety of programs and
services are available which afford eligible students with disabilities the opportunity to participate fully
in all aspects of college programs and activities utilizing appropriate and reasonable accommodations.
I. Paperwork Requirements:
1) Students receiving services through the Disabilities Services Center must have a disability
which is verified by an appropriate professional. There must be evidence that a “major
life activity” (e.g. learning, walking, seeing, hearing) requires accommodation(s) to ensure
an equal opportunity for success in college coursework.
2) All medical and/or verification forms must be returned with the completed application.
II. Student Requirements:
1) Students must meet with a Disability Services professional to establish an Academic
Accommodation Plan (AAP) and to update the Notification of Accommodation Services (NAS)
once a semester to be eligible for priority registration.
2) Comply with the Student Code of Conduct adopted by Yosemite Community College District
(YCCD). Additionally, students are expected to comply with the DSPS handbook.
3) Possess the ability to comprehend questions, follow directions, and demonstrate the potential
to benefit from programs and services at MJC. Must demonstrate measureable academic
progress.
4) Disability Services does not provide attendant care. Students must arrange for and provide
individual attendant care if necessary.
5) Students are responsible for all DSPS testing policies and procedures. See DSPS Handbook.
I understand that I must fulfill the requirements for participation in DSPS and understand
the consequences of failing to comply with the rules for responsible use of disability
services. I understand that I will be notified in writing before any action is taken to
suspend services, and that I also have the right to appeal any decision regarding
suspension of services.
By signing this application I affirm that I understand and agree with DSPS student
responsibilities and I will abide by them. You agree your electronic signature is the
equivalent of your manual signature on this application.
Student Signature: Date:
Modesto Junior College uses the information requested on this form for the purpose of determining a student’s
eligibility to receive authorized special services provided by DSPS. 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 California Community Colleges Chancellor’s Office 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). Pursuant to Section 7 of the Federal
Privacy Act (Public Law 93-579; 5 U.S.C. § 552a, note), providing your social security number is
voluntary. The information on this form is being collected pursuant to California Education Code Section 67310-
67312 and 84850; and California Code of Regulation, Title 5 Section 56000 et seq.
Rev. 3/10/20
DISABILITY SERVICES & PROGRAMS FOR STUDENTS
ACCOUNTABILITY CONTRACT
ALL scheduled appointments for DSPS services require a student to provide the disability
services office with no less than a 24 hour advanced notification, when cancelling
any appointment. An appointment may be cancelled by contacting (209)575-6225.
If there is no answer, please leave a message.
Services requiring appointments include, but are not limited to:
* Advising/Counseling Appointments
* Alternate Media Appointments
* Interpreter/Captioning Services
* Testing Accommodations
* Learning Disability Testing
Students requesting alternate media and interpreter/captioning services need to:
* Request services as soon as possible after registering for classes.
* Notify DSPS Specialist when adding and dropping classes.
* Expect a reasonable turnaround time of up to 10 working days.
* Return any issued equipment by the due date.
Students requesting testing accommodations need to:
* Make request at least 4 working days before date of the exam(s).
* Notify the testing center about the need of reader/scribe as approved by counselor.
* Have all testing materials such as pencil, blue/green book, scantron upon arrival.
* If an emergency should arise and you cannot take the test during the scheduled time,
contact your instructor and the testing center before the scheduled time.
* Prearrange testing time accordingly to testing center hours.
* * * DUE TO LEARNING DISABILITY TESTING BEING CONDUCTED IN OUR OFFICE,
PLEASE DO NOT BRING CHILDREN WITH YOU FOR A COUNSELING APPOINTMENT * * *
LATE ARRIVAL NOTICE
If you are more than 5 minutes late to a 30-minute appointment or 10 minutes late to a 1-
hour appointment, you will have to reschedule your appointment.
Failure to comply with the 24-hour cancellation policy WILL result in the loss of services
UNTIL student meets with the Dean of Student Services or their designee to receive
clearance.
By signing this accountability contract, I understand and agree with Disabled Student
Programs and Services policy and procedures. You agree your electronic signature is the
equivalent of your manual signature on this application.
Print Name Student ID#
Signature Date
☐
☐
☐
☐
☐
☐
☐
☐
☐
Diagnosis of disability signed by an appropriate medical practitioner, psychologist or other
specialist
Test results from other agencies which were used for determination of eligibility
Name of Institution
Audiology and speech/language pathology reports
California Community College LD Eligibility Verification
Vocational Rehabilitation Plan
Individual Education Plan (IEP) and Psycho-Educational Evaluation Report
List of Accommodations Needed
Department of Veterans Affairs
Other
Rev. 3/10/20
MODESTO JUNIOR COLLEGE
DISABILITY SERVICES & PROGRAMS FOR STUDENTS (DSPS)
Request for Release of Information
RE:
Student Name (Please Print) DOB MJC Student ID Number
TO:
Licensed Professional Phone Fax
Street Address City/State Zip
I authorize the release of information to include one or more of the following records
identified below:
I further give permission for Disability Services staff to discuss my educational situation
with other professionals who have a legitimate educational need to know. You agree your
electronic signature is the equivalent of your manual signature on this application.
Student Signature Date
(or parent/guardian signature if student is under the age of 18)
A photocopy of this document is as valid as the original. This authorization shall remain in effect until removed
in writing by the student.
Modesto Junior College uses the information requested on this form for the purpose of determining a student’s
eligibility to receive authorized special services provided by the Disability Services Center. 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). Pursuant
to Section 7 of the Federal Privacy Act (Public Law 93-579;5 U.S.C. § 552a, note), providing your social security
number is voluntary. The information on this form is being collected pursuant to California Education Code
Section 67310-67312, and 84850; and California Code of Regulations, Title 5 Section 56000 et. seq.
Rev. 3/10/20
Disability Services & Programs for Students
Verification of Disability
The student named below has requested services/accommodations at Modesto Junior College
FIRST NAME MIDDLE INITIAL LAST NAME DOB:
MAILING ADDDRESS CITY STATE ZIP PHONE NUMBER
1 Diagnosis:
☐ Autism Spectrum
☐ ADHD
☐ Other:
☐ Intellectual Disability
☐ Physical Disability
☐ Blind & Low Vision
2. This disability is:
3. This disability is:
☐ Acquired Brain Injury
☐ Learning Disability (must include test scores)
☐ Deaf & Hard of Hearing
☐ Mental Health Disability- DSM-V Code (s)
☐ Permanent/Chronic
☐ Observable
☐ Temporary: months
☐ Not Observable
4. Educational/Functional Limitations:
☐ Auditory Processing ☐ Visual Processing
☐ Academic Deficits ☐ Easily Distracted
☐ Limited Ambulation ☐ Poor Concentration
☐ Difficulty Formulating and executing plan of action ☐ Visual Acuity right eye left eye
☐ Difficulty Overcoming Unexpected Obstacles
☐ Panics in Unfamiliar Surroundings and Situations
☐ Hearing Loss (current audiogram)
☐ Other (Please Describe)
5. Recommended Services/Accommodations:
☐ Assistive Listening for Hearing Impaired ☐ Interpreter (Sign Language)
☐ Note Taker (NCR paper) ☐ Reading Magnifying Machine ☐ Scribe
☐ Accessible Textbooks
☐ Audio Record Lectures
☐ Test Taking (Extended Time, Distraction Reduced Setting) ☐ Other
6. Reduced Units: ☐ 3-6 ☐ 6-9 ☐ 9-11
Licensed Professional Only
Print Name: Date:
Signature of Licensed Professional:
License Number: Phone Number
PLEASE BRING, FAX OR EMAIL THIS FORM TO:
Modesto Junior College
Disability Services & Programs for Students
Student Services Building, Room 112
435 College Avenue Modesto, CA 95350
PHONE #: (209)575-6225 or FAX (209) 575-6852
EMAIL mjcdsps@mjc.edu
Option 1
Option 2
Attach a copy of your IEP or 504 Plan from high school.
This form must be completed by a Licensed Professional. Items 1 through 6 must be answered.
Reports and scores must be included for some disabilities.
– OR –
(Submit documentation for both options if requesting accommodations for different disabilities)
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Modesto Junior College
Disability Services and Programs for Students
Voter’s Registration Statement
Students with disabilities have the right to voter registration opportunities. For
more information, please ask one of the Disability Services personnel, or visit the
Voter’s Registration link at https://registertovote.ca.gov/
Provisions of the National Voter registration Act of 1993 Section 7 requires states
to offer voter registration opportunities at all office that provide public assistance
and all offices that provide state-funded programs primarily engaged in providing
services to persons with disabilities. Each applicant for any of these services,
renewal of services, or address changes must be provided with a voter
registration form of a declination form as well as assistance in completing the
form and forwarding the completed application to the appropriate state or local
election official. More information can be found at the following website:
https://registertovote.ca.gov/
S
tudent Name: Student ID:
S
ignature: Date:
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signature
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Rev. 3/10/20
Chancellor’s Office For California Community College defines the following disabilities:
Acquired Brain Impairment: a verified deficit in brain functioning which results in a total or partial loss of
one or more of the following: cognitive, communicative, motor, psychosocial or sensory perceptual abilities.
Communication Disability: an impairment in the process of speech, language or hearing.
a) Hearing impairment means a total or partial loss of hearing function, which impedes the communication
process essential to language, educational, social and/or cultural interactions.
b) Speech and language impairment: one or more speech/language disorder of voice, articulation, rhythm
and/or the receptive and expressive processes of language.
Intellectual Disability:
a) Potential and measurable achievement in instructional or employment setting
Learning Disability: (Learning disabilities will be verified through evaluation process using the California
Community College eligibility criteria.) Learning disability is defined as a persistent condition of presumed
neurological dysfunction, which may exist with other disabling conditions. This dysfunction continues despite
instruction in standard classroom situations. To be categorized as learning disabled, a student must exhibit:
a) Average to above average intellectual ability
b) Severe processing deficit(s)
c) Severe aptitude achievement discrepancy(ies) and
d) Measured achievement in an instructional or employment setting
Other Disabilities: all other verifiable disabilities and health functional limitations that adversely affect
education performance but do not fall into any of the other disability categories. Other disabilities include
conditions having limited strength, vitality, or alertness due to chronic or acute health problems. Examples are
environmental disabilities, speech disorders, heart conditions, tuberculosis, nephritis, sickle cell anemia,
hemophilia, leukemia, epilepsy, acquired immune deficiency syndrome (AIDS), and diabetes.
Physical Disability: a visual, mobility, or orthopedic impairment
a) Visual impairment means total or partial loss of sight.
b) Mobility and orthopedic impairment means a serious limitation in locomotion or motor functions, which
indicate a need for special services or special classes.
Mental Health Disability: for purposes of service delivery in the educational setting, means a condition which:
a) Is listed in the American Psychiatric Association Diagnostic and Statistical Manual (DSM) and is coded on
axis I or II as moderate to severe, and
b) Reflects a psychiatric or psychological condition that interferes with major life activity, and
c) Poses a Functional Limitation in the educational setting.
Attention-Deficit/Hyperactivity Disorder: Attention-Deficit Hyperactivity Disorder is defined as a
neurodevelopmental disorder that is a persistent deficit in attention and/or hyperactive and impulsive behavior
that limits the student’s ability to access the educational process.
Autism Spectrum Disorder: Autism Spectrum disorders are defined as neurodevelopmental disorders
described as persistent deficits which limit the student’s ability to access the educational process. Symptoms
must have been present in the early developmental period, and cause limitations in social, academic,
occupational, or other important areas of current functioning.
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Completed 4 September 2020

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