Full Name *

First Name Last Name

Pronouns

She/Her He/Him They/Them Other

Student ID Number *

10 digits

Phone Number *

Email *

example@example.com

Date of Birth *

Month Day Year

Request for services are campus specific. Which semester are you requesting DSPS Services for your City College classes? (Please Note: If you are taking classes at Mesa or Miramar you must also contact their DSPS Department for services.) *

Fall 2020 Intersession 2021 Spring 2021

Have you ever attended City College before? *

Yes No

Have you received DSPS services from any of the following Colleges before? *

Yes, City (prior to Fall 2019) Yes, Mesa College Yes, Miramar College Yes, Continuing Education No, I have not received DSPS Services from any other college Other

Are you currently in high school needing accommodations for a City College classes taught at your high school site (known as CCAP)? *

Yes No

If you answered yes: what high school do you go to?

Are you receiving services from any of the following:

Department of Rehabilitation *

Yes No

Regional Center *

Yes No

Veteran's Services *

Yes No

What academic difficulties are you currently experiencing? *

What is your current educational goal? *

In your own words please describe your disability *

Disability Information-Check All that Apply

Hearing Loss:

Deaf Hard of Hearing Use Sign Language Cochlear Impact/Hearing Aid

Mobility:

Cerebral Palsy Multiple Sclerosis Orthopedic Respiratory Spinal Cord Injury Other

Mental Health:

History of Mental Health Challenges History of Substance Abuse Inpatient/Outpatient Counseling

Vision Challenges:

Blind Low Vision

Other Disabilities:

AIDS/HIV Attention Deficit Disorder (ADD/ADHD) Autism Asperger Syndrome Diabetes Epilepsy/Seizures Gastrointestinal Disorder Immune System Disorder Other

Learning Disability (has been verified by):

High School University CA Community College Other

Verification of Disability Requirement

Verification of Disability (VOD) is required to determine eligibility for DSPS Services. Please select one option below (required). *

I have VOD (MedicalRecord, IEP, 504, VA ratings etc.) and will upload it below using the browse/file upload option. I have VOD (Medical Record, IEP, 504, VA ratings etc.) and will email it to citydsps@sdccd.edu I submitted VOD to Mesa, Miramar or Continuing Education, please request it from them. I submitted VOD to City College as I was previously registered with City DSPS. Please Note: If it was prior to Fall 2015 we will likely need you to resubmit VOD. I do not know how to get VOD I do not have VOD, but believe that I might have a learning disability and would like to schedule an appointment with the Learning Disability Specialist for a screening.

If you have access to your disability verification (Medical Record, IEP, 504, VA ratings etc.) please upload the documents here.

What is your preferred method of contact? *

Email Phone Call Text Chat Zoom Video Conference

What is the best time to reach you? Select all that apply? *

9:00 am - 11:00 am 11:00 am - 1:00 pm 1:00 pm - 3:00 pm 3:00 pm - 5:00 pm

What days are you available?

Monday Tuesday Wednesday Thursday Friday

Acknowledgements & Agreements

FERPA Disclaimer

Due to the abrupt transition to remote services as a result of the national emergency with COVID-19,we are having to get creative in the way we offer supports and services to students remotely. In order to comply with Family Educational Rights and Privacy Act (FERPA), a two question identification authentication will be required prior to releasing any academic information over the phone on in the remote counseling environments.

I hereby grant permission for San Diego City College Remote DSPS Counselors to release academic information about myself during a live remote counseling appointment, via the phone, email or ConferZoom online meeting tool, to myself. When requesting a remote appointment and while communication with the counselor questions, I must authentically represent myself in all aspects.

FERPA Disclaimer Agreement *

I acknowledge that I have read and agree to the above two paragraphs

By typing in your full name and submitting this form you are authorizing the college to conduct business on your behalf for the purpose of processing your DSPS application *

Disability Support Programs and Services (DSPS) Application for Services

Are you receiving services from any of the following: