6/05/19
Yuba College
Disabled Students Programs and Services (DSPS)
Student Intake Application
Name Student ID#
Date of Birth Phone
Do you have an advocate? [ ] No [ ] Yes Advocate Name/Agency
Are you under conservatorship? [ ] No [ ] Yes If yes, please provide a copy of the conservatorship.
CURRENT ENROLLMENT:
[ ] Yes, #units [ ] No, when? Major/Area of Interest
Educational and/or Career Goal
Prior college experience
Student Services Received: [ ] Financial Aid [ ] EOP&S [ ] CalWORKs [ ] Veterans [ ] C.A.R.E
DESCRIPTION OF YOUR DISABILITY:
Your age when the disability first occurred?
How do you believe that your disability impacts your educational participation?
ADDITIONAL HEALTH INFORMATION:
Diagnosed with vision problems [ ] No [ ] Yes Describe
Corrective lenses? Date of last eye exam
Diagnosed with hearing problems [ ] No [ ] Yes Describe
Hospitalized for a major head injury [ ] No [ ] Yes Unconscious? [ ] Yes [ ] No How Long?
Describe:
Learning Disabilities [ ] No [ ] Yes If yes, where and when?
ADD/ADHD [ ] No [ ] Yes If yes, where and when?
Physical Disability or Injury [ ] No [ ] Yes Disability/injury?
Psychological Disability [ ] No [ ] Yes Diagnosis
History of Substance Abuse [ ] No [ ] Yes Time sober/clean years months
In individual/group counseling [ ] No [ ] Yes Therapist
Medication(s) for disability [ ] No [ ] Yes Current Medications
Medicine side effects
Describe any current family or personal situations (positive/negative) which are impacting the student’s education at
this time:
Notes:
By completing this form, I am applying for Yuba College Disabled Students Programs and Services.
STUDENT SIGNATURE DATE
STAFF SIGNATURE DATE
