Application for Services Rights & Responsibilities Student Name: Porterville College DRC - Application - Revised May 2019 Student ID: @ Academic Year Street Address: Phone Number: PC Email: @ Disability Information Disability/Diagnosis: Office: Office: Department of Rehabilitation Central Valley Regional Center Student rights The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act state that students with disabilities have the following rights: Equal access to postsecondary education Reasonable academic accommodations Keeping disability information confidential Equal participation in college activities Freedom from discrimination Set up accommodations with the Vice President of Student Services (AC-126), if student does not want to participate in DRC program Student responsibilities Please answer Yes or No on each line to acknowledge your responsibilities as a student of the DRC program. Turn in application paperwork with Verification of Disability (VOD). For temporary disabilities, update VOD once every academic year. VOD may include: - Verification of Disability form, signed by appropriate licensed professional - 504 Plan or Individualized Educational Plan (IEP) Complete Orientation once upon intake into program, then once every academic year. Schedule Intake interview with a counselor after turning in application paperwork. Complete Academic Accommodation Plan (AAP) with a counselor once every semester. Complete Student Educational Plan (SEP) with counselor and update it if changing majors/classes. Turn in Progress Report mid-semester every semester. Return all borrowed books & equipment to DRC at the end of every semester. Comply with the Porterville College Student Conduct policies. Student Conduct Handbook is available at https://www.portervillecollege.edu/student-services/student-conduct-and-discipline I agree to fulfill the above requirements in order to receive DRC services. I understand that if I do not fulfill the above requirements, I may not be able to use book lending or equipment lending services. Student’s Signature: Date: Porterville College and Kern Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services proved by the DRC Program. 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 statues regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C SS 1232G). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. 522a, note), providing your social security number is voluntary. 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. Office Use Only: Application Received Date:
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Application for ServicesRights & Responsibilities
Student Name:
Porterville College DRC - Application - Revised May 2019
Student ID: @ Academic Year
Street Address: Phone Number:
PC Email: @
Disability Information
Disability/Diagnosis:
Office:
Office:
Department of Rehabilitation
Central Valley Regional Center Student rights
The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act state that students with disabilities have the following rights: Equal access to postsecondary education Reasonable academic accommodations Keeping disability information confidential
Equal participation in college activities Freedom from discrimination
Set up accommodations withthe Vice President of StudentServices (AC-126), if studentdoes not want to participatein DRC program
Student responsibilities
Please answer Yes or No on each line to acknowledge your responsibilities as a student of the DRC program.
Turn in application paperwork with Verification of Disability (VOD). For temporary disabilities, update VOD once every academic year.
VOD may include: - Verification of Disability form, signed by appropriate licensed professional- 504 Plan or Individualized Educational Plan (IEP)
Complete Orientation once upon intake into program, then once every academic year.
Schedule Intake interview with a counselor after turning in application paperwork.
Complete Academic Accommodation Plan (AAP) with a counselor once every semester.
Complete Student Educational Plan (SEP) with counselor and update it if changing majors/classes.
Turn in Progress Report mid-semester every semester.
Return all borrowed books & equipment to DRC at the end of every semester. Comply with the Porterville College Student Conduct policies. Student Conduct Handbook is available at https://www.portervillecollege.edu/student-services/student-conduct-and-discipline
I agree to fulfill the above requirements in order to receive DRC services. I understand that if I do not fulfill the above requirements, I may not be able to use book lending or equipment lending services.
Student’s Signature: Date: Porterville College and Kern Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services proved by the DRC Program. 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 statues regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C SS 1232G). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. 522a, note), providing your social security number is voluntary. 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.
Office Use Only: Application Received Date:
Authorization for Release ofStudent Records
In accordance with the Family Rights and Privacy Act (FERPA), the Disability Resource Center (DRC) may only release student records directly to the student, unless prior written authorization is given by the student. By filling out this form
you give permission to others to view and have access to your student records. STUDENT INFORMATION
Last Name:
Revised May 2019
First Name: Student ID or Last 4 digits of SSN:
Email: @ Phone: Date of Birth:
Street Address: City: State:
INDICATE WHICH RECORDS TO BE RELEASED
All Academic Records (records include: transcripts, admissions and registration information, class schedules, grades, assessment test scores, academic progress status, academic probation, residency information, and any other documentation contained in the academic records).
DSPS Services (records include: DRC program application status, educational limitations related to my disability, recommended accommodations, services approved by DRC counselor/coordinator, and all other information relating to my academic accommodations).
Verification of Disability (records include: verification of disability (VOD) form, medical records, doctor’s note, individualized education plan (IEP), 504 plan, and any other documents used to verify eligibility for DRC services).
Other (Please specify)
I authorize the release of all information concerning my educational and disability accommodations records to the individual(s) listed below. I understand that if I choose to cancel this authorization, I must provide a written notice to the DRC. If I wish to have my educational and disability accommodations records released to any other person(s) after this date, I must complete a new FERPA release form.
Name Relationship SSN (Last 4 digits) Phone
Name Relationship SSN (Last 4 digits) Phone
Provider, School, or PC Instructor Name and Contact Information
Before any of your student information is released, the above person(s) must be able to verify their relationship to you, the last four digits of their own social security number, and all the following information about you:
Full Name Social Security Number Date of Birth
By signing this document, you consent to the release of your educational and disability accommodations information to the individual(s) listed above. This consent applies to educational records that may otherwise be protected under the Family Educational Rights and Privacy Act (FERPA) of 1974, as amended by, 20 U.S.C. 123g.
I understand that although I am not required to release this information, I am giving my consent to Porterville College to disclose these records. Initials
This authorization shall stay in effect for the current academic year only or until I revoke it, if earlier. Initials
Student Signature Date
OFFICE USE ONLY
Government Photo ID Verified
Verification of Disability (VOD)
Fall
Revised May 2019
Spring Summer 20
STUDENT: COMPLETE THIS SECTION
Student Name: Student ID#: @Date of Birth: Phone: I am a student at Porterville College. I authorize my medical provider to release disability-related information to Porterville College Disability Resource Center (DRC) in order to determine appropriate accommodations. Porterville College DRC may contact my medical provider for additional information or clarification, if needed.
Student Signature: Date:
LICENSED* PROFESSIONALS ONLY: Complete this section
Please see back of form for qualified licensed professionals
Provider’s name: Title: Address: Phone: Specific Diagnosis(es): Type of Disability:
Acquired Brain Injury Intellectual Disability Deaf/Hard-of-HearingLearning Disability Mobility Impairment Speech/Language ImpairmentVisual Impairment Autism Spectrum ADHDMental Health Disability: DSM V AXIS I & II Diagnosis Codes:
Other Disability(ies):
Duration (This section must be completely filled out for the student to receive services.) Permanent Chronic/recurring (Likely to last for duration of college attendance.)
Temporary Date disability will end: (Accommodations not necessary after this date.)
Educational/Functional Limitations Producing in-class notes, assignments, or other written requirements Taking tests in traditional manner
Hearing or processing lectures or other verbally presented information Scheduling and registering for courses
Completing course requirements without specialized tutoring Acquiring knowledge of college and community resources
Moving around campus or classroom (for temporary disability only)
Seeing or processing visually presented classroom materials, texts, or other printed materials
Using college facilities, equipment, and materials. Explain:
P
Rrodu
ecommended Services/Accommodations:
Signature: Date:
Mail, Fax, or E-mail to: Porterville College Disability Resource Center – 100 E. College Ave – Porterville, CA. 93257
Porterville College and Kern Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services proved by the DRC Program. 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 statues regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C SS 1232G). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93 - 579; 5 U.S.C. 522a, note), providing your social security number is voluntary. 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.
• Documentation of Mobility Impairment and Psychological Disability should be dated within 90 days of therequest.
• All others should be dated within 3 years of the request.
Disability & Licensed Professional Required Documentation
High School students, submit most recent Individual Education Plan and:
Acquired Brain Injury (deficit in brain functioning resulting in loss of cognitive, communicative, motor, psychological, and/or sensory/perceptual abilities) • Neurologist or Neuropsychologist• Physician
• Cognitive rehabilitation report/neurologicalassessment/medical report documenting the disability
• Description of the impact on cognitive functions or howable the student is to take in and remember newinformation and produce reports based on new learning.
Intellectual Disability formerly Developmentally Delayed Learner (below average intellectual functioning and potential for measurable achievement in instructional and employment settings)
• Psychiatrist• Psychologist
• Regional Center certification and/or psychological report(usually WAIS III or WISC III) documenting the disability
• Standard scores and/or descriptions of adaptive behaviorlevels
• Standard scores (not grade level equivalents nor percentileranks) from recent academic achievement assessment(reading, spelling, math, etc.)
Hearing Impairment (loss of hearing function which impedeslanguage, educational, social, and/or cultural interactions) • Audiologist• Certified Otologist
• Current audiogram documenting the disability• Educational Limitations• Recommended Services / Accommodations
Learning Disability (average to above average intellectual ability; severe processing deficit; severe aptitude-achievement discrepancy; and measured achievement)
• Ed. Or Clinical Psychologist; Psychiatrist• College/University LD Specialist
• Psychological report documenting the disability• Cognitive ability test standard scores (usually the WAIS III
or WISC III)• Achievement test standard scores (usually the WJIII)• Educational Limitations• Recommended Services/Accommodations
Mobility Impairment (Serious limitation in locomotion and/or motor function) • Physician; Nurse Practitioner
• Medical report documenting the disability (within 90 days)• Educational Limitations• Recommended Services/Accommodations
Psychological Disability (persistent psychological/psychiatricdisorder; emotional or mental illness) • Psychiatrist; Psychologist• MFCC or MSW; Physician
• Psychological report documenting the DSM Code and Axis(within 90 days)
Speech & Language Impairment (disorders of voice, articulation, rhythm, and/or receptive and expressive processes) • Speech and Language Pathologist
• Speech/Language report documenting the disability• Educational Limitations• Recommended Services/Accommodations
Visual Impairment (Total or partial loss of sight) • Ophthalmologist; Optometrist
• Current vision test documenting the disability• Educational Limitations• Recommended Services/Accommodations
Other Disability (does not fall into any of the above disabilitiesbut indicates a need for support services). Includes AD/HD. • Appropriate Professional• AD/HD: Psychologist, Psychiatrist, or Physician
• Medical or professional report documenting the disability• Educational Limitations• Recommended Services/Accommodations
Definitions are according to Title 5 of the California Code of Regulations for California Community Colleges
DRC INTAKE INTERVIEW
Student must complete packet themselves. Student Name: Student ID#: @ Date Completed:
Preferred Language:
Revised 4.2.19 - Porterville College DRC - Intake Interview -
Emergency Contact(s) Name Relationship Phone
Programs and Services
1. Do you have an IEP/504 plan from K-12th grade? Yes No
2. Were you ever tested for eligibility in special education prior to college? Yes No
If yes, when and why:
3. Have you ever received services from any of the following? Check all that apply. Yes No
DSP&S EOPS CARE SSDI FYSP CalWORKs Other:
4. Have you ever been a c lient of the Department of Rehabilitation (DOR)? Yes No
If yes, what is your disability according t o DOR?
5. Have you ever been a c lient of the Regional Center (CVRC)? Yes No
6. Have you ever been in foster care? Yes No
7. Are you a veteran? Yes No
Health History
8. Do you have vision problems or wear glasses / contacts? Yes No
If yes, describe:
9. Do you have problems hearing? Yes No
If yes, describe:
10. Are you taking any medications? Yes No
If yes, describe: Name(s) of medication(s)
Dosage(s):
For what condition(s):
Side effects:
How long have you been taking them? 11. Was there anything unusual about your early development, s uch as delayed speech, late
crawling o r walking, problems using scissors, reading or writing?Yes No
If yes, please explain:
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12. Have you ever had a ny serious injuries or illnesses? Yes No
Revised 4.2.19 - Porterville College DRC - Intake Interview -
If yes, describe how it impacted y our education:
13. Over the l ast 2 weeks, h ow often have you been bothered by any of the following problems?Please note, all fields are required.
1. Little interest or pleasure in doing things.
Not at Al l Severa l Days More than hal f days
2. Feeling down, depressed, or hopeless.
Not at Al l Severa l Days Mor e than hal f day s
3. Trouble falling or staying a sleep, or sleeping t oo much.
No t at All Severa l Days More than half days
4. Feeling t ires o r having lit tle energy.
No t at All Severa l Days Mor e tha n ha lf days
5. Poor appetite or overeating.
Not at Al l Severa l Days More than half days
6. Feeling bad abou t yoursel f - o r tha t you are a failure o r have le t yourself o r you r family down.
Not at Al l Severa l Days More than hal f days
7. Trouble concentrating on things , such as reading the newspape r o r watching television.
Not at Al l Severa l Days More than hal f days
8. Moving o r speaking so slowly tha t othe r people could h ave noticed.
Not at Al l Severa l Days More than hal f days
9. Thoughts tha t you would be bette r of f dead , o r o f hurting yourself.
Not at Al l Severa l Days More than hal f days
10. I f you have checked of f any problems , how d ifficul t have these problems m ade i t for you a t work , home , or withother people.
Not at All Several Days More than half days
Educational Background
14. In what academic a reas have you experienced difficulty? Check all that apply.
Reading Study skills Completing a ssignments on time Spelling
Reading rate Organizing written work Math Comprehending concepts
Taking t ests Self-confidence in school Retaining in formation Motivation
Memory Concentration Other:
Describe your difficulties:
15. When did you first start having p roblems at school?
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16. Why do you think you had problems in school? Check all that apply.
Specific Learning Disability Tasks too difficult Home environment
Revised 4.2.19 - Porterville College DRC - Intake Interview -
Lack of interest in school Limited a bility Emotional problems
Poor attendance Retaining in formation Motivation
Memory Other:
17. Did you frequently change schools in elementary or secondary school? Yes No
If yes, explain:
18. Were you retained in school/held back to repeat a grade? Yes No
If yes, what grades did you receive and why?
19. Have you ever been in special education, remedial, or gifted c lasses? Yes No
If yes, what types of classes? Check all that apply.
Specific Learning Disability Tasks too difficult Home environment
Speech & language services Gifted classes Other:
20. What school subjects are you best at/do you enjoy the most?
21. Have you attended any other college(s) or university(ies)? Yes No
If yes, how many units did you complete?
22. Are you currently enrolled a t Porterville College? Yes No
If yes, how many units? How many hours p er week do you study?
23. Are you currently on academic p robation? Yes No
If yes, why?
24. Have you ever used tutoring or mentoring services? Yes No 25. What are your goals for attending college?
College major:
Family History
26. Does anyone in your family have a learning d isability? Yes No
If yes, describe:
27. Does anyone in your family have any type of disability, such as physical, emotional, vision,hearing, mobility etc?
Yes No
If yes, describe:
28. Describe any current family or personal issues which are impacting your education:
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Work History
29. Are you currently employed? Yes No
If yes, please describe:
Where?
Number of hours per week:
Job t itle:
What is your weekly work schedule?
How long have you had this job? Years Months Weeks
Revised 4.2.19 - Porterville College DRC - Intake Interview - Page 4 of 4
If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Check One)
Already registered. I am registered to vote at my current residence address.
Yes. I would like to register to vote. (Please fill out the attached voter registration form.)
No. I do not want to register to vote.
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 TAKE THE ATTACHED VOTER REGISTRATION FORM TO REGISTER AT YOUR CONVENIENCE.
___________________________________________________________________ Applicant Name Date
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 thisagency.
2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept helpis 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 indeciding whether to register or in applying to register to vote, or your right to choose your own political party preference orother 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.
