Public Accommodation Request

* indicates a required field

CHAFFEY COLLEGE DPS APPLICATION

As part of the registration process, you will be required to upload documentation, such as a Disability Verification Form, please have the COMPLETE document ready to upload before filling out this application. The form can't be processed without documentation (please include ALL pages of your documents), but you can contact us at DPS.records@chaffey.edu for help.

The preferred file format is .pdf. If you have any questions about what documents we can accept please email us at DPS.Records@chaffey.edu and we will help you.

First Name

Last Name

Middle Name

Student ID

Please use your Chaffey College ID. In order to apply for DPS, you will need to be a Chaffey student. If you just applied to Chaffey, please allow at least 3 business days to receive your ID. Please enter your ID like this, without letters: "0######"

Please enter your Panther email with Chaffey. If you don't have one, please put your personal email.

Phone Number

Date of Birth

Example: MM/DD/YYYY

Any Relevant Medications?

(If necessary, please attach a list of your medications below.)

Allergies:

Please indicate any severe allergies. Put "None" if you have no allergies.

Specific Accommodation Information

What kinds of accommodations are you hoping to receive or have received in the past?

If you have never received accommodations before please let us know here. Please be aware that your answer here is not an official request, official requests should be made and discussed during your appointment with a DPS counselor

Have you received accommodations at another college?

Did you have a 504 Plan or IEP and Psychoeducational Report in high school?

Do you have any known medical conditions?

Are you enrolled in classes at Chaffey College right now?

Please indicate your Academic and Career Community

Your Academic and Career Community is based on your major or your general area of interest. If you're not sure, please select "I don't know".

Please indicate your Academic and Career Community Arts, Communication, and Design Please indicate your Academic and Career Community Business, Technology, and Hospitality Please indicate your Academic and Career Community Health, Wellness, and Athletics Please indicate your Academic and Career Community Manufacturing, Industrial Design, and Transportation Please indicate your Academic and Career Community Public Service, Culture, and Society Please indicate your Academic and Career Community Science, Mathematics, and Engineering Please indicate your Academic and Career Community I don't know

How did you hear about us?

Is the person filling out this form the student seeking accommodations?

Click "yes" if you are the student who wants to join DPS and you are filling in your own information into this form. Click "no" if you're a preparer who is filling out this form on behalf of the student who is applying to DPS.

Upload Your Supporting Document(s) Here:

To be approved, you will need to attach COMPLETE documentation (including ALL pages if it has multiple pages) which clearly states your diagnosis.

These documents can be one or a combination of the following:

- Your latest IEP and Psychoeducational Report if you had one in high school.

Please note Chaffey College accepts your IEP And Psychoeducational Report for eligibility purposes only. Post-secondary education systems such as Chaffey College may not adhere to the accommodations and services as they were listed in your IEP/Psychoeducational Reports from high school.

- A letter written on letterhead and signed by a doctor or qualifying professional (for example: therapist, psychologist, medical doctor, case worker, etc.) stating your diagnosis. For letters from private practitioners, please include a license number.

- Documents from a the Disability Program and Services department of another college you attended.

- A Disability Verification Form completed by a doctor or certified pr
ofessional (if you need this form, please email us at DPS.Records@chaffey.edu and we will send it to you).

Link: https://www.dropbox.com/s/ewx7ci7qyvu23n8/CURRENT_Medical%20Verification%20Form_fillable.pdf?dl=0

The preferred file format is .pdf. If you have any questions about what documents we can accept please email us at DPS.Records@chaffey.edu and we will help you.

Are you Senior Early Transition?

Are you applying through the DPS Senior Early Transition program through your high school?

Public Accommodation Request

CHAFFEY COLLEGE DPS APPLICATION

Specific Accommodation Information

Document Information