Transition to College/DRD Request for Services

Personal Information:

First Name

Last Name

Pronouns

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

Date of Birth (mm/dd/yyyy)

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.

I am requesting (please check all that apply):

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

Additional Info:

Are you a US Veteran?*

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.

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, Jacobs Hall, Room 101

*** 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)

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:*

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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Use your mouse or finger to draw your signature above

Parent/Guardian if student is under 18

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Use your mouse or finger to draw your signature above

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