DSPS High School Application

Disabled Student Programs & Services

High School Student Application to Request Academic Adjustments, Auxiliary Aids, Services and/or Instruction
Columbia College provides academic adjustments, auxillary aids, services and/or instruction for students with verified disabilities and provides learning disabilities testing review through Disabled Student Programs & Services (DSPS).

The Yosemite Community College District uses the information requested below to determine a student’s eligibility to receive authorized academic adjustments, auxillary aids, services, and/or instruction provided by the Disabled Students Programs and Services (DSPS) Program. Personal information recorded on this form will be kept confidential 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 (FERPA) (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).
High School Information

Enter basic contact information here
Application Date *

Month Day Year
High School *

Amador High School Argonaut High School Bret Harte High School Calaveras High School Don Pedro High School Gold Rush Charter Mariposa High School Oakdale High School Sonora High School Summerville High School Tioga High School
High School Contact Person *
High School Contact Phone Number *

Area Code Phone Number
High School Contact Email *
example@example.com
Student Demographics

Enter your personal information in this section
Student Name *

First Name Middle Name Last Name Suffix
Student W Number *
Enter your Columbia College Student W Number Here.
Date of Birth *

Month Day Year
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Student Email *
example0999999@my.yosemite.edu
DSPS sends reminders for appointments, college deadlines and alerts, and other essential DSPS information. Please select a method of delivery. *

Text Message Email
Confirm Cell Phone number for alerts *
Confirm Email for alerts *
Disability Information

Upload IEP or 504 here
Please check any disabilities which may apply to you *

56032. Physical Disability 56034. Deaf and Hard of Hearing (DHH) 56035. Blind and Low Vision 56036. Learning Disability 56037. Acquired Brain Injury (ABI) 56038. Attention-Deficit Hyperactivity Disorder (ADHD) 56039. Intellectual Disability (ID) 56040. Autism Spectrum 56042. Mental Health Disability 56044. Other Health Conditions and Disabilities
Did your disability/disabilities occur at birth? *

Yes No
At which age did your disability/disabilities occur? *
Please briefly describe how your disability impacts your education *
Disability Documentation Type you are uploading *

IEP 504
Upload your IEP or 504 here. *

Browse Files

Cancel of
Certification of Information

and signature
Thank you for your interest in services through Columbia College DSPS.
- This application is in compliance with the Family Educational Rights and Privacy Act (FERPA) 20 U.S.C. § 1232g; 34CFR Part 99.
- FERPA is a Federal law that protects the privacy of student educational records.
- The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.
By signing below I hereby authorize Columbia College Disabled Student Programs and Services Certificated Staff, to notify my instructor(s) that I have a verified disability and I am eligible for appropriate accommodations which will facilitate my success in the classes at the community college. Staff may also follow-up with my instructor(s) regarding my progress in courses. This release will remain in effect so long as I am a student with Columbia College. I may be requested to sign a new instructor release as a returning student depending on the amount of time I have been away from Columbia College.
Signature Acknowledgement

I am 18 years of age or older I am 17 or younger and my parent/guardian is present during this application I am 17 or younger and my parent/guardian is NOT present during this application
My signature certifies the application information I provided is true and correct to the best of my knowledge. *

Clear
Name of parent or guardian authorized to call and speak with DSPS about your accommodations *
Relationship to Student *
Password for authorized person *
The authorized person must provide this password when they contact DSPS, otherwise DSPS will not disclose any of your information.
Signature of parent/guardian if student is under 18 years of age *

Clear
A parent/guardian signature is required for all applicants under the age if 18. Since a parent/guardian was not present during this application we will need a form sent to the parent/guardian for signature. A link to that form is provided below. Please copy and email the link to the parent/guardian.

Please submit this form today and we will hold the application until we receive the parent/guardian signature. The parent/guardian signature form will automatically be sent to us once completed and submitted.

COPY AND SEND LINK BELOW TO PARENT/GUARDIAN FOR SIGNATURE

https://pdf.ac/4UbKfh
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Disabled Student Programs & Services

High School Information

Student Demographics

Disability Information

Certification of Information