College of the Redwoods provides educational services and access for eligible students with documented disabilities who intend to pursue coursework at College of the Redwoods. A variety of programs and services are available which afford eligible students with disabilities the opportunity to participate fully in all aspects of college programs and activities through appropriate and reasonable accommodations. Completion of this form constitutes an agreement to apply for Disabled Student Programs & Services (DSP&S).

(Please Print) NAME:_________________________________ *SSN#: ________________________
ID#:___________________________
ADDRESS:___________________________________________________________________________
CITY:________________________ STATE:___________ ZIP:________________
PHONE: ( )_______________ DOB:_____________ MALE_____ FEMALE_____
DISABLING CONDITION:______________________________________________________________
PHYSICIAN:______________________________________
EMERGENCY CONTACT (NAME/NUMBER): _______________________________________________

I am requesting DSPS services. I understand that DSPS services will not be provided until verification of disability is received and my DSPS student education contract is complete. I understand that DSPS services are directly related to the educational process at CR and may not apply to other institutions or organizations.

*The Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services provided by the Disabled Students Programs and Services (DSP&S) Program. Personal information recorded on this form will be kept confidential in order 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 (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), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000 et seq.

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Disability: primary __________ Disability: secondary __________

Responsible party: (self/other) ___________________________________________________________________

1. Mob 2.Vis 3. Other 4. Hearing 5. Speech 6. LD 7. ABI 8. DDL 9. Psych / Sub Abuse (in treatment) 10. Undecided

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DISABLED STUDENT PROGRAMS AND SERVICES (DSPS)

DSPS STUDENT RIGHTS:

1. My participation in DSPS shall be entirely voluntary.
2. Receiving DSPS support services or instruction shall not preclude me from also participating in any other course, program or activity offered by the college.
3. All records maintained by DSPS personnel pertaining to my disabilities shall be protected from disclosure and shall be subject to all other requirements for handling of student records.
4. If an agreement between faculty member, DSPS professional and myself cannot be reached, regarding services and accommodations, I understand that I may appeal through the formal College of the Redwoods grievance process.

DSPS STUDENT RESPONSIBILITIES:

1. I will provide Disabled Student Programs & Services with the information, documentation and/or forms (medical, educational, etc.) deemed necessary by DSP&S to verify my disability(ies).
2. I will meet with a DSPS professional to complete a Student Educational Contract and then meet with the professional once each semester to update the Support Services Agreement.
3. I will utilize the Disabled Student Programs & Services in a responsible manner. I understand that the Disabled Student Programs & Services uses written service provision policies and procedures that must be adhered to or continuation of services.
4. I will make measurable progress towards the goals established in the Student Educational Contract and meet academic standards established by College of the Redwoods.
5. I will comply with the Student Code of Conduct adopted by College of the Redwoods.

I understand that I must fulfill the requirements for participation in the DSP&S Program. I have received a copy of the policy on suspension of DSP&S services, and I understand the consequences of failing to comply with the rules for responsible use of DSP&S services. I understand that I will be notified in writing before any action is taken to suspend services. By signing this application I affirm that I understand and agree with the DSP&S Program responsibilities of students and I will abide by them.

Student Signature________________________________ Date________________