9/line Intake Form

B Number

How does this disability limit your education?

Are you currently a client with the Department of Rehab?

Are you currently taking any medications that may influence your educational performance?

Please list any services you have received from any prior institutions. For example, accommodations listed on a high school IEP.

9/line Rights and Responsibilities

Barstow Community College District provides educational services and access for students with documented disabilities who intend to pursue coursework at Barstow Community College. A variety of programs and services are available which gives students with disabilities the opportunity to participate fully in all aspects of Barstow Community College programs and activities through appropriate and reasonable accommodations. By completing this form, I am applying for services from 9/line through the Accessibility Coordination Center and Educational Support Services (ACCESS).

Rights:

My participation in 9/line shall be entirely voluntary.

Receiving support services or instruction from 9/line through ACCESS shall not preclude me from also participating in any other course, program, or activity offered by Barstow Community College, or from receiving basic accommodations required by state and federal law.

I have been advised that a copy of the ACCESS Student Handbook (policies & procedures) and the opportunity to register to vote in local, state, and national elections via “Motor Voter Registration” is available to me on the Special Programs and Services Canvas webpage.

All records maintained by 9/line personnel pertaining to my disability (s) shall be protected from disclosure and shall be subject to all other requirements for handling student records.

Responsibilities:

I will provide 9/line with the necessary documentation and/or forms (medical, educational, etc.) to verify my disability.

I will meet with a 9/line Counselor to complete an Academic Accommodation Plan (AAP), and also meet with a 9/line counselor at least once per semester to update the Academic Accommodation Plan.

I will utilize 9/line services in a responsible manner. I understand that 9/line uses written service provision policies and procedures, which must be adhered to for the continuation of services.

I will comply with the Student Code of Conduct adopted by Barstow Community College.

I must demonstrate measurable progress toward the goals established in my Student Education Plan (SEP).NOTE: Authorities cited: Title 5 C.C.R. Section 56000 m., Education Code Sections 66701, 67310-37612,70901, and 84850.

I understand and agree to the above Student Rights and Responsibilities, and I will abide by them. I give permission for 9/line staff to discuss my educational situation with other professionals who have a legitimate educational need to know.

9/line Consent of Release: I, the undersigned, request any appropriate person and/or agency or institution to release information consistent with the Federal Education Rights and Privacy Act of 1974, or other laws, regulations, or policies to Barstow Community College for use in educational/career planning. All information will be kept confidential and maintained as part of my records with 9/line as Barstow Community College. I authorize the release of information to include any records or documentation that verifies my disability to 9/line staff. I further give my permission to 9/line staff to discuss these records with other professionals at Barstow Community College who have a legitimate educational need to know, and I give permission for 9/line to forward these records to other educational institutions upon my written request. This authorization shall remain in effect until revoked in writing by the undersigned.

Main Campus

Fort Irwin Campus