DSPS Application for Services

CONFIDENTIAL

Saddleback College provides educational services and access for eligible students with documented disabilities who intend to pursue coursework at Saddleback College. 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 DSPS.

Fields marked with * are required.

Personal Information

Student ID # *

First Name *

Last Name *

Middle Name Initial

Email Address *

Birth Date *

Month

Day

Year

Phone Numbers

Home Phone Number

May we leave a confidential message at this home number? *

Yes

Mobile Phone Number

May we leave a confidential message at this mobile number? *

Yes

Address

Street 1 *

Street 2

City *

State *

Zip *

Emergency Contact Info

Phone Number

Contact Name *

Disabilities/Health/Learning Problems *

What services do you wish to receive? *

Specified Services *

Do you have a Dept. of Rehabilitation counselor? *

Yes

Name of Dept. of Rehabilitation Counselor

If you have medical, educational, or related documentation available, you may upload it here.

Files must be less than 10 MB.
Allowed file types: jpg jpeg png pdf zip.

If you are not registered to vote where you live now, would you like to apply to register to vote now? *

I am already registered to vote at my current address.

Yes, I would like to register to vote. Please navigate to this site.

No, I do no want to register to vote.

Student Responsibilities

I will provide DSPS with the information, documentation and/or forms (educational, psychological, medical, etc.) deemed necessary by DSPS to verify my disability(ies).
I will meet with a DSPS professional to complete a Student Educational Contract, and agree to meet with a DSPS counselor or specialist at least annually to update the Student Educational Contract.
I will utilize DSPS in a responsible manner. I understand that DSPS uses written service provision policies and procedures that must be adhered to for continuation of services.
I will comply with the Student Code of Conduct adopted by the college. (Click here to view the Saddleback College Student Handbook.)

Understand Requirements Agreement *

* I understand that I must fulfill the requirements for participation in DSPS. I have read the DSPS Services Agreement. I understand the consequences of failing to comply with the rules for responsible use of these services. I understand that I will be notified in writing before any action is taken to suspend services. By submitting this application, I affirm that I understand and agree with the Student Responsibilities, and I will abide by them (see www.saddleback.edu/dsps).

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)). 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.

Leave this field blank

Locations:
Main Office SSC 113
Accommodated Testing Center Village 28-1
Alt Media Village 23-1
Learning Disability Center SSC 224
Main Office Phone:
(949) 582-4885
Accommodated Testing Center:
(949) 582-4424
Learning Disability Center:
(949) 582-4246
Video Phone:(949) 482-4430
Fax: (949) 347-1526

Main Office Email: scdsps@saddleback.edu Accommodated Testing Email: scatc@saddleback.edu

Office Hours:

Monday - Thursday
8:00 AM - 4:30 PM
Friday
8:00 AM - 12:00 PM

DSPS Coordinator:
Michael Hoggatt
Interim Coordinator