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ACCESS Intake Form/Voters Preference Registration Form

Disability Information

ACCESS 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 the Accessibility Coordination Center and Educational Support Services (ACCESS).



My participation in ACCESS shall be entirely voluntary.

Receiving support services or instruction 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 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 ACCESS Personnel pertaining to my disability (s) shall be protected from disclosure and shall be subject to all other requirements for handling of student records.



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

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

I will utilize ACCESS services in a responsible manner. I understand that ACCESS 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 ACCESS staff to discuss my educational situation with other professionals who have a legitimate educational need to know.

Voters Preference Registration

Students Name
If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Check One Box)
Sign above
Important Notices
1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this
2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the voter registration form in private.
3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in
deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or
other political preference, you may file a complaint with the Secretary of State by calling toll-free (800) 345-VOTE (8683)
or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. For more information on elections and
voting, please visit the Secretary of State’s website at