Interactive Intake Application

* indicates a required field

Student Information

Please complete this intake application and submit it to the Disability Resource Center (in Building 1600, Room 1615) along with documentation of your disability prior to your scheduled appointment with a Disabled Student Program and Services (DSPS) Counselor. Some sources of documentation that are commonly used to verify a disability include, but are not limited to the following:

• Appropriate agencies such as K-12 school districts, other colleges/universities, Regional Centers, Veteran’s Affairs, social and/or governmental service agencies, and

• Certified or licensed professionals such as Medical Doctors, Clinical Psychologists, Therapists, Ophthalmologists, Audiologists, and Speech Therapists.

Do your best to be as detailed as possible when completing this application. Any additional information that you would like to add is welcome. You will review the forms and the application at your intake appointment, so you may ask questions at that time about items you did not understand. Your responses, the documentation of disability that you provide, and the intake appointment with the DSPS Counselor will be used to determine eligibility for services. Information you share with the DSPS is confidential, protected by the Family Educational Rights and Privacy Act (FERPA) of 1974, and will not be part of your academic record at Las Positas College (LPC).

First NameRequired *

Last NameRequired *

Middle Name

W#:Required *

Contact Phone:Required *

Email (1):Required *

Please use your college issued email address

Email (2):

If we call you by phone, may we leave you a voice message?

If we call you by phone, may we leave you a voice message? Yes If we call you by phone, may we leave you a voice message? No

Are you a registered LPC student?

Are you a registered LPC student? Yes Are you a registered LPC student? No

For how many semesters?

Has your mathematics and/or English placement been determined at LPC?

Has your mathematics and/or English placement been determined at LPC? Yes Has your mathematics and/or English placement been determined at LPC? No

List the highest level math classes you took in High School:

List the highest level English classes you took in High School:

Have you completed the LPC online orientation?

Have you completed the LPC online orientation? Yes Have you completed the LPC online orientation? No

Is English your first language?

Is English your first language? Yes Is English your first language? No

What is your first language?

What other support services are you currently receiving at LPC?

Career Center CalWORKs EOPS/CARE Financial Aid HSI Mental Health Services Middle College Puente Transition to College Umoja Veteran's First

What are your educational goals?

Associate Degree & transfer Associate Degree without transfer Transfer Earn a Vocational Certificate Acquire job skills Update job skills Personal Enrichment Improve basic skills (i.e., English, Math) Undecided Other

Major:

Have you received DSPS services at another college or university?

Have you received DSPS services at another college or university? Yes Have you received DSPS services at another college or university? No

Which college/university?

Dates:

Are you a client of the Department of Rehabilitation?

Are you a client of the Department of Rehabilitation? Yes Are you a client of the Department of Rehabilitation? No

Are you (or have you even been) a Regional Center client?

Are you (or have you even been) a Regional Center client? Yes Are you (or have you even been) a Regional Center client? No

List the Regional Center(s):

In high school, I was in or had (check all that apply):

Regular classes Special day classes Resource program IEP 504 plan Other (please describe below)

If 'Other', please describe:

California Voter RegistrationRequired *

Voter RegistrationRequired *

https://registertovote.ca.gov/?t=vra&id=87

Disability Information

Select all disabilities that apply to you:Required *

Briefly explain how the disability/disabilities you indicated affect(s) your learning?

Are you able to upload documentation verifying this disability or disabilities?

Are you able to upload documentation verifying this disability or disabilities? Yes Are you able to upload documentation verifying this disability or disabilities? No

Upload documentation verifying this disability or disabilities here:

Do you have a physician who can verify this disability or disabilities?

Do you have a physician who can verify this disability or disabilities? Yes Do you have a physician who can verify this disability or disabilities? No

Are you currently taking medication?

Are you currently taking medication? Yes Are you currently taking medication? No

Please provide the name of the medication, dosage, and list the side effects:

Emergency Contact Information

Name:

Relationship:

Emergency Contact Phone (1):

Emergency Contact Phone (2):

Student Rights and Responsibilities

Qualified students with a verified disability, have the right to receive reasonable academic accommodations based on an educational limitation. The college faculty and staff shall not automatically reject an accommodations unless other effective, more feasible ones exist, or the identified accommodations will fundamentally alter the nature of the program or course in question. As a DSPS program student, the following rights and responsibilities is apply to me.

STUDENT RIGHTS

1.Required *

Participation in DSPS shall be entirely voluntary.

I acknowledge.

2.Required *

Receiving DSPS support services/accommodations, or DSPS instruction shall not preclude you from participating in any other course, program, or activity offered by the college. No student shall be discriminated against on the basis of disability.

I acknowledge.

3.Required *

Students have the right to file grievance if they have been discriminated against by following complaint process on the college website at http://www.laspositascollege.edu/dsps/complaint-form.php. Students may also communicate their complain in writing to the DSPS Director at lpc-dsps@laspositascollege.edu.

I acknowledge.

4.Required *

All records maintained by DSP personnel pertaining to your disabilities shall be protected from disclosure and shall be subject to the FERPA requirements for handling of student records.

I acknowledge.

5.Required *

Students have the right to receive academic accommodations as documented in their DSPS Academic Accommodation Plan (AAP) after plans are shared with instructors.

I acknowledge.

STUDENT RESPONSIBILITIES

6.Required *

Students must provide the necessary documentation to verify a disability.

I acknowledge.

7.Required *

Students are required to follow the “Student Code of Conduct” as published in the Las Positas College catalog.

I acknowledge.

8.Required *

Students will meet with a DSPS counselor to complete an Academic Accommodation Plan (AAP) and agree to meet with their DSPS counselor every semester to renew academic accommodation.

I acknowledge.

9.Required *

Students are responsible to provide their Academic Accommodation Plan (AAP) to faculty members in a timely manner.

I acknowledge.

10.Required *

Students will request accommodations, alternative media, testing accommodations, and appointments according to the established program guidelines.

I acknowledge.

11.Required *

Students must notify the DSPS office in advance of any absence from class or appointments if you are using readers, interpreters, and/or other assistance.

I acknowledge.

12.Required *

Students must return equipment on loan from the DSPS at the end of each semester.

I acknowledge.

*Note: Unreturned equipment may result in loss of service and/or holds placed on student accounts.

FAILURE TO FOLLOW THE WRITTEN POLICIES OF THE DSPS PROGRAM MAY JEOPARDIZE THE CONTINUATION OF SERVICES.

In such instances, the DSPS Director will notify you in writing that you are in violation of the DSPS policies and procedures and that if you continue to be in violation, services may be suspended or terminated. In all instances were services may be suspended or terminated, students will be invited to discuss in individual situations before any action is taken. Students will also be notified in writing of the process for appeal of any decision that suspends or terminates services.

I have read and understand the DSPS Student Rights and Responsibilities (copies available at DSPS Office).Required *

Type your name.

Interactive Intake Application

Student Information

Disability Information

Emergency Contact Information

Student Rights and Responsibilities

Document Information