Disability Resources Department (DRD)- Request for Services

FormTitle

Disability Resources Department (DRD) Request for Services

Personal Information:

First Name

Last Name

Pronouns

. he/him/his she/her/hers they/them/theirs

Other:

Date of Birth (mm/dd/yyyy)*

Date of Birth (mm/dd/yyyy)

Student ID number*

Student ID number

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (include area code)

Email

At which campus would you prefer to meet your Disability Specialist?

Santa Rosa Petaluma

What is the nature of your disability? (Check all that apply):

Please check the one that applies:

I have a verified learning disability and can provide testing reports. I wish to be tested for eligibility for learning disability services. In high school, I received LD Services through Special Education.

Please check box for psychological diagnosis:

Depression PTSD Anxiety/Panic Schizophrenia Eating Disorder

Other:

I am requesting (please check all that apply):

*** Please Note: SRJC does not provide personal attendants.***

Additional Info:

Are you a current high school student?*

Yes No

I am currently enrolled in classes at SRJC.

YES NO

I plan to start classes at SRJC in

Summer Spring Fall Already Registered I am not sure yet about my plans for after high school, but I am interested in receiving updates from SRJC in the meantime.

What year?

Are you incarcerated or formerly incarcerated?

Yes No

Are you a US Veteran?*

Yes No

Are you an SRJC student-athlete? (Includes intercollegiate or club sports) or in the SRJC Dance Program? (This does NOT include PE or Adapted PE.)*

Yes No

Check all services that you receive:*

Department of Rehabilitation North Bay Regional Center Cal Works Program Not Applicable

DOR Counselor's Name:

Client Program Coordinator's (CPC) Name:

List Disabilities and/or Conditions. Please include onset ages and how they affect you in a classroom setting:

List any medications you are currently taking. Please include the dosages and the side effects of each:

Have you ever had a seizure?

Yes No

Do you use a wheelchair?

Yes No

Are you able to find your way around campus?

Yes No

Do you require a personal attendant?

Yes No

For which of the following would you require an attendant (check all that apply):

Eating Restroom Transfer Dressing

SRJC does not provide personal attendants. Are you able to provide your own attendant?

Yes No

Have you ever had a brain injury?

Yes No

What type of brain injury did you have?

Stroke Head Trauma Tumor

Other:

Were you hospitalized?

Yes No

For how long?

Are you currently receiving therapy?

Yes No

What kind of therapy? (check all that apply):

Physical Occupational Speech Psychological

Verification of Disability:

You will need to include documentation of your disability:

Medical verfication (e.g., ADHD, Autism, Seizure Disorder, Vision, etc.)

AND/OR

Educational verification documents such as a 504 Plan or IEP (Individual Education Plan)

If you have documentation, please use the button below to upload it now.

***If your verification is password protected, the upload will not work. Please email your medical verification todisabilityinfo@santarosa.edu . Be sure to include the password in your email. Thank You. ***

You may download and print the form below for Medical Verification of Disability. It must be completed by a certifying medical professional (medical doctor or other licensed certifying professional such as Psychologist/Physical Therapist/State of CA Vocational Rehab Counselor).

MEDICAL VERIFICATION FORM (click to download/print)

Once the form is completed, you may submit it to DRD by:

1. Scanning and emailing to disabilityinfo@santarosa.edu

2. Faxing the document to 707-524-1768

3. By mail: Disability Resources, 1501 Mendocino Ave, Santa Rosa, CA 95401

4. In person: Santa Rosa campus, Bertolini 3rd Floor

Petaluma Campus, Richard Call Building, Room 600

*** Please Note: Request for Disability Services cannot be processed until Verification of Disability is received.***

Upload Verification of Disability documentation here:

No File Chosen

File uploads may not work on some mobile devices.

Check here if you do not have access to documentation of your disability. DRD will contact you directly.

I do not have access to documentation of my disability. I am not sure if I'm eligible for disability services.

We need your permission to retain these documents in your confidential file:

The documentation of my disability is from (name of Agency/Provider):

Contact Name/Title

Phone Number (include area code)

Email

Notice: Under state law, all information you supply to Santa Rosa Junior College is maintained in student records that are subject to inspection by the named student.

Please check the authorizations below:*

I have provided the Santa Rosa Junior College Disability Resources Department (DRD) with copies of school and/or medical records containing information regarding my disability in order to receive disability support services at Santa Rosa Junior College. I authorize any appropriate person and/or agency/institution listed above to release/disclose to Santa Rosa Junior College DRD, information pertaining to my disability, diagnosis, history and/or treatment. I give permission for the ongoing exchange of information between Santa Rosa Junior College, Disability Resources Department (DRD) and Agency/Provider, listed above, pertaining to my academic success.

Permission will remain in effect while I am active in DRD or until this specified date (mm,dd,yyyy):

Permission to Contact:

I give permission to the staff of Disability Resources Department at Santa Rosa Junior College (SRJC) to contact me and leave messages identifying themselves, SRJC, and the Disability Resources Department regarding appointments and business with the department by telephone, U.S. mail and/or email.

***This permission will remain in effect until- (list the date you think you will be enrolled until). If date is left blank, then this permission will be effective for four (4) years from date on form.

Check your preferred method of contact: (check all that apply)

Phone- at the numbers I provided to SRJC Mail- at the address I provided to SRJC Email- at the address I provided to SRJC

Date

Student Responsibilities:

I will provide SRJC's Disability Resources Department with the documentation and/or forms (medical, educational, etc.) necessary to verify my disability.
I will meet with a Disability Specialist to complete an Academic Accommodation Plan and will meet at least annually to update the that contract.
I will use the Disability Resources Department services in a responsible manner.
I will comply with the Student Code of Conduct adopted by SRJC.

I hereby request services from SRJC's DSP&S program. I have read the Student Responsibilities and agree to participate. I understand there are Grievance Procedures, posted on the college website, which I can follow should I disagree with decisions about my disability related services.

Student's Signature*

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National Voter Registration Act- Voter Preference Form

If you are not registered to vote where you live now, would you like to apply to register to vote today? (Check One) *

Already registered. I am registered to vote at my current residence address. Yes. I would like to register to vote. No. I do not want to register to vote. I am 16 or 17 years old and would like to pre-register to vote. I understand that that I will automatically be registered to vote on my 18th birthday.

I need help from Disability Resources to fill out a Voter Registration Card. I will pick up a Voter Registration Card from Disability Resources and complete it on my own. I will register to vote online on my own. (You will receive an email with the link to the voter registration website after submitting this form)

NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. YOU MAY COMPLETE A VOTER REGISTRATION FORM TO REGISTER AT YOUR CONVENIENCE.

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 this
agency.
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.

Signature*

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Please review your responses now. You will not be able to edit your responses once you click "submit".