NCC DSPS Intake Packet

Nevada County Campus SAS Application

Student File / Information Form
STUDENT FILE INFORMATION/APPLICATION FORM*

NewContinuingReturning
Application Date*

MonthDayYear
Date
Name*
Student ID*
111-111-115
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone *
Birthdate *

MonthDayYear
Date
Email*
example@sierracollege.edu
Emergency Contact
Name
Emergency Contact Relationship
Mom / Dad/ Uncle... etc.
Emergency Contact Phone
Disabling Conditions:*
Disabling Condition Verification:

Please upload verification of disability (IEP, 504 Plan, Doctor's Note, Medical Records, etc.)
Cancelof
AGENCY:
I.Private / State Rehabilitation Counselor
I.Private / State Rehabilitation Counselor Address
I.Private / State Rehabilitation Counselor Phone
2. Alta Regional Center
2. Alta Regional Center Address
2. Alta Regional Center Phone
Are you a Veteran*

YESNO
Who referred/recommended that you contact DSPS?
College Major*
Other colleges attended:

Procedures for Obtaining Academic Accommodations
Student Responsibilities:

1. Student must be enrolled in Sierra College classes and provide the DSPS office with a written verification of disability including identification of educational limitations due to the disability.

2. Each semester, and/or as needed during the semester, the student must schedule an appointment to meet privately with a DSPS certificated faculty member to request academic accommodations. The student may, at any time, also request the accommodation directly from the classroom faculty member.

3. The DSPS certificated faculty member will evaluate the requested accommodation and complete a Disabled Student Services Academic Accommodation Certification form. A copy of the form will be provided to the student and a copy will be maintained in the student's DSPS file.

4. If a student disagrees with the accommodation he/she should contact the DSPS certificated faculty member to meet and discuss the accommodation. If the student continues to disagree with the accommodation he/she will be referred to the district's DSPS Coordinator or designee.

5. The district DSPS Coordinator or designee will discuss and confer with the DSP&S certificated faculty member, the class instructor and other resources as appropriate to review the student's disability and make a determination within 5 (five) instructional days from the date the student contacted the Coordinator.

6. If the student is still not satisfied with the disposition of the accommodation, the district DSPS Coordinator will refer the request to the SCCD ADA/504 Compliance Officer. The SCCD ADA/504 Compliance Officer will confer with all necessary parties and make a final determination on behalf of SCCD within 30 (thirty) instructional days from the date the Certification form was signed.

I understand these procedures and agree to abide by them.
Signature*

Clear
Date:*

MonthDayYear
Date

Student Rights and Responsibilities
Student Rights

1. My participation in the Disabled Students Programs & Services (DSPS) will be entirely voluntary.

2. Receiving support service or instruction through DSPS will not preclude me from also participating in any other course, program, or activity offered by the college or from receiving basic accommodations required by state and federal law.

3. All records maintained by DSPS personnel pertaining to my disability will be protected from disclosure and will be subject to all other requirements for handling of student records.

NOTE: Authorities cited: Title 5 C.C.R., Section 56000 et seq .. Education Code Sections 66701, 67310-67312, 70901,84850.

Student Responsibilites

1. I will provide DSPS with the necessary information, documentation and/or forms (medical, educational, etc.) to verify my disability.

2. I will meet with a DSPS professional to complete a Student Education Plan (SEP), and request an Academic Accommodations Certification form. I understand that I am responsible for communicating this information to my instructors.

3. I will utilize DSPS in a responsible manner. I understand that DSP&S uses written service provision policies and procedures, which must be adhered to, for continuation of services.

4. I will comply with the Student Code of Conduct adopted by the college (see Student Handbook).

5. I must demonstrate measurable progress toward the goals established in my Student Educational Plan.
I understand and agree to the above Student Rights and Responsibilities and I will abide by them. I give permission for the DSP&S staff to discuss my educational situation with other professionals who have a legitimate educational need to know. I have been given a copy of this document. If l do not comply with these rights and responsibilities, I understand that services may be suspended or terminated.
Signature*

Clear
Date*

MonthDayYear
Date

Consent for Release of Information
Name*
Date of Birth*

MonthDayYear
Date
Student ID*
Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Maiden name or other name used
I, the undersigned, request any appropriate person/or agency or institution to release information consistent with the Federal Family Educational Rights and Privacy Act of 1974, or other laws, regulations, or policies to the college for use in educational/vocational planning. All information will be kept confidential and maintained as a part of my records with the DSP&S Office at the college. Selected information may be released for mandated State and/or Federal reports. I authorize the release of information which may include one or more of the following records:
I, the undersigned, request any appropriate person/or agency or institution to release information consistent with the Federal Family Educational Rights and Privacy Act of 1974, or other laws, regulations, or policies to the college for use in educational/vocational planning. All information will be kept confidential and maintained as a part of my records with the DSPS Office at the college. Selected information may be released for mandated State and/or Federal reports. I authorize the release of information which may include one or more of the following records:

Verification of DisabilityPsychological Testing and Evaluation ResultsLearning Disability AssessmentVocational Rehabilitation PlanEducational Records, including progress madeOutside AgencyParent(s) / Guardian - Type name below
I further give my permission for DSPS certificated staff to discuss my educational limitations with other professionals who have a legitimate educational need to know.

THIS AUTHORIZATION SHALL REMAIN IN EFFECT DURING MY ENROLLMENT OR UNTIL REVOKED IN WRITING.
Signature of Student*

Clear
Date*

MonthDayYear
Date
Signature of Parent or Guardian required for student under 18 years of age

Clear
Date

MonthDayYear
Date
NCC SAS Email
sasncc@sierracollege.edu

DSPS Voter Preference Form
Under the National Voter Registration Act (NVRA) of 1992, DSPS is an Agency-Based Registration Site, where students have the opportunity to become registered voters during the application process. There is no obligation to register to vote and the student's decision will have no effect on services offered by DSPS. To be eligible to register to vote, you must be a U.S. Citizen, and meet all eligibility requirements.
Name*
Student ID*
111-111-115
Date*

MonthDayYear
Date
If you are not registered to vote where you live now, would you like to apply to register to vote here today? Select one of the following.
NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
You indicated above that you wish to register to vote. Please click on the following link to register. This link will open in a new window. When complete, please return to finish submitting this form.

Voter Registration Form
Important Notices

1) Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by thisagency.

2) If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private.

3) If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or other political preference, you may file a complaint with the Secretary of State by calling toll-free (800) 345-VOTE (8683)or you may write to: Secretary of State, 1500 -11th Street, Sacramento, CA, 95814. For more information on elections and voting, please visit the Secretary of State’s website at www.sos.ca.gov.
Should be Empty:

Nevada County Campus SAS Application

AGENCY:

Procedures for Obtaining Academic Accommodations

Student Rights and Responsibilities

Consent for Release of Information

DSPS Voter Preference Form