SAN DIEGO COMMUNITY COLLEGE DISTRICT (SDCCD)
Disability Support Programs and Services (DSPS)
Application for Services
G:\data\share\dsps\Forms\ApplicationPaperwork\Application for Services 06-01-12.doc
TODAY’S DATE: __________________ CSID: ______________________
Last Name:_________________________________ First Name: __________________________________ MI:___________
Address:_______________________________ City, State and Zip:_______________________________________________
DOB:_____________________ Home Phone:________________________ Cell Phone: __________________________
E-mail Address: __________________________________________________________________
Emergency Contact Person________________________________________________________
Relationship to Student: : _________________________________ Phone:
GENERAL INFORMATION
Have you applied to City, Mesa, Miramar College(s) (Admissions)? Yes _____ No _____
Have you taken the College/CE Assessment/Placement Tests? (if yes, include scores if available)
MATH: No____Yes_________________ ENGLISH: No____Yes_________________ ESL: No____Yes_________________
DEAF ENGLISH: No____Yes_________________ TABE: No____Yes_________________
What is your current educational goal (if known)? ____________________________________________________________
Would you like assistance with Voter Registration? Yes____ No____
Have you ever received services from any SDCCD DSPS Office? No____ Yes____ Year_______ Where? ______________
Are you receiving services through? (check all that apply)
____EOPS ____Cal WORKS ____WorkAbility III ____Financial Aid ____SSI/SSDI ____Veterans
____Department of Rehabilitation ____Regional Center ____TRACE ____Other (list here) _________________
Counselor(s):___________________________________________________________________________________________
EDUCATIONAL HISTORY
Are you having academic difficulties? (describe)_______________________________________________________________
What is the highest level of education completed? (Check all that apply)
8 9 10 11 12 HS diploma GED Cert. of Completion
Highest college degree completed_____________________________________Graduation Date: ______________________
High School or other Colleges attended: _____________________________________________________________________
Have you ever received Special Ed./504/IEP/Resource/Remedial support? Yes ____ No ____
If you are currently working, please describe employment:
Where? _________________________________________________________________________________________
