Santa Monica College
DISABLED STUDENT PROGRAMS & SERVICES
APPLICATION FOR SUPPORT SERVICES

INITIAL DATE OF APPLICATION FOR SERVICES
Enter Semester Year
Nature of Disability

OFF CAMPUS AFFILIATIONS


If yes, name of your rehabilitation counselor

Rehabilitation Counselor

Regional Center


Regional Center Counselor

Psychological services

Psychologist

EMERGENCY CONTACT PERSON

EDUCATIONAL HISTORY

Employment History

I agree that if necessary for medical or educational purposes, or if necessary for the safety of myself, or
others, information about me may be released to, or obtained from an instructor, relevant agency, or family
member. I understand that information contained in my file will be available to the California Community
College Chancellor's Office if they request it for an audit, a program evaluation, or educational research.

Signature:______________________________________________ Date:________________________

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