MASTER - DSP Application for Services 2020-2021 Rev. 11/15/17
Academic Year: 2020 2021
Date of Birth:
Telephones: (H) (C)
Are you a client of the Dept. of Rehabilitation? Yes No
DSP Overview:
Solano Community College (SCC) provides educational services and access for eligible students with
documented disabilities who intend to pursue coursework at SCC. 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 through appropriate and (reasonable accommodations). Completion of this form
constitutes an agreement to apply for services from DSP.
Student Responsibilities: (Please read carefully)
1. I understand that I am required to provide the Disability Services Program with written documentation (ex:
medical, educational, or psychological forms, etc. to verify my disability.
2. I will meet with a DSP staff person to complete my Application for Services and the Educational Assistance
and Measurable Progress Form (EAMP). I agree to meet with my counselor once per semester to
discuss my progress in classes. I understand that I must also renew my Application for Services and
the EAMP Form each fiscal year for which I choose to utilize DSP Services.
3. I will utilize DSP in a responsible manner, and understand that DSP has written policies and procedures that
must be adhered to for continuation of services.
4. I will comply with the Student Code of Conduct adopted by the college.
I understand that I must fulfill the requirements stated above for participation in DSP. I understand the consequences
of failing to comply with the rules for responsible use of DSP services. I understand that I will be notified in writing
before any action is taken to suspend services. By signing this application I affirm that I understand and agree with the
DSP Program responsibilities of students, and I will abide by them.
Student Signature Date DSP Certificated Staff Signature Date
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)). 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 Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000
et seq.
Primary/Secondary Disability Categories
____ ABI ____ DHH ____ Mental Health ____ ADHD ____ Autism ____ Physical Disability
____ LD ____ ID ____ Blind and Low Vision ____ Other Health Conditions __________________
For MIS Staff Use Only: Summer _____ Fall _____ Spring _____
Gender: M F
Decline to State
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