DSPS

General Information

Name *

Student ID *

Email Address *

Address *

City *

Zip

Phone (Home) *

Phone (Work)

Date Of Birth *

Age

Gender
Male Female

College Major

Prior Schools Attended (High School. College, and University)

College Units Completed

Who referred you to our program?

Name / Agency

What is your disability?

Describe your disability

Do you have another disability? If so, describe:

What are your educational goals?
AA Degree
Transfer to a four year college with/without AA
Vocational Certificate Program
Basic Skills
Personal Enrichment

What type of services do you feel you may need:

Check the age when your primary disability occured:
At birth
5 years or younger
6-18 years
19-37 years
38-55 years
56 + years

If yes,

Counselor's Name

Phone

Address

City

Zip

Are you recieving services from any other campus or community program? If so please describe

Are you receiving (Please check all that apply)
SSI
SSA or
SSDI

Are you recieving Finanical Aid?
Yes N o

If you applied for financial aid, what semester / year did you apply?

Have you recieved disabled student services from any college prior to attending MiraCosta?
Yes No

Emergency Information

Are you taking any medication at the present time?
Yes No

Name of Medication

Dosage

Name of Medication

Dosage

Doctor who can verify your disability:

Name

Address

City

Zip

Phone

List name of person to be notified in case of emergency:

Name

Relationship

Phone

Address

Zip

BY CHECKING THE BOX BELOW, I CERTIFY THAT THE FOREGOING STATEMENTS ON MY APPLICATION FOR DISABLED STUDENT PROGRAM & SERVICES ARE COMPLETE AND ACCURATE.

I AGREE:

THERE ARE INSTANCES WHEN COMMUNICATION IS NEEDED WITH INSTRUCTORS EVEN PRIOR TO ACCEPTANCE BY DSP&S FOR SERVICES. COMMUNICATIONS PERTAIN TO EDUCATIONAL INFORMATION. BY CHECKING THE BOX BELOW, I HERBY AUTHORIZE DISABLED STUDENT PROGRAMS AND SERVICES TO RELEASE TO MY INSTRUCTORS INFORMATION FROM MY RECORDS WHICH BEARS ON MY EDUCATIONAL DEVELOPMENT.

I AGREE: