Student Request for Services

Thank you for your interest in the Disability Resource Center! In order to successfully submit this form, you will need to use Mozilla Firefox or Google Chrome as your Internet browser. If you do not have either browser running on your computer, you can download them for free at the following websites:

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The following questions will help us understand how to best assist you. A few of the questions pertain to "accommodations." Accommodations are resources, tools, or strategies that minimize the impact of disability symptoms (e.g. Notetaking assistance):

Strongly DisagreeDisagreeSomewhat DisagreeSomewhat AgreeAgreeStrongly Agree
Question 2
Strongly DisagreeDisagreeSomewhat DisagreeSomewhat AgreeAgreeStrongly Agree
Question 3
Strongly DisagreeDisagreeSomewhat DisagreeSomewhat AgreeAgreeStrongly Agree
Question 5
Strongly DisagreeDisagreeSomewhat DisagreeSomewhat AgreeAgreeStrongly Agree
Question 6

We will need documentation verifying your disability as soon as possible. In the meantime, please complete this form so we may begin reviewing your needs. If you don't have any documentation (paperwork) verifying your needs, please provide the appropriate document(s) from the list below to your diagnosing professional and have him/her send it to us. You can also send us any applicable documents using the upload buttons at the bottom of this page, drop them off at our office, or fax them to: 805-756-5451. Please call us at 805-756-1395 if you have any challenges or questions.

Form for Medical, Physical and/or Mobility Impairments (PDF)

Guidelines for Assessment and Accommodation of Students with Learning Disabilities (PDF)

Psychological Disability (PDF)

AD/HD (PDF)

Visual Impairment (PDF)

Deaf/Hard of hearing (PDF)

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

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