DSPS Application for Services

Student Information

Please complete all fields below

First Name

Last Name

Hartnell ID#

Email

Please use your @student.hartnell.edu email address

Phone Number

I am an active client of the Department of Rehabilitation

I am receiving financial aid at Hartnell

I am a Veteran

How would you describe your disability?

Please describe your disability if you selected "other" above

What educational difficulties do you experience because of your disability?

What campus(es) will you be attending?

Check all that apply.

Have you obtained one of the following:

Were/are you in Special Education in High School?

Did/do you have an IEP or 504 Plan?

I authorize DSPS to share disability related information at Hartnell College with the following outside agencies:

Please list any outside agencies that you consent for DSPS to release information to

I authorize DSPS to share disability related information at Hartnell College with the following family members

Please list all family members that you consent for DSPS to release information to. If none, please type "N/A"

Please select all departments that you consent for DSPS to release information to

Upload supporting document(s)

To electronically submit an IEP, 504 Plan, or other documents, please upload here.

When electronic submission is not available, please bring in person to DSPS office.