ACCESS Intake Form/Voters Preference Registration Form

B Number

Telephone 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.

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).

Rights:

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.

Responsibilities:

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.

ACCESS 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 ACCESS as Barstow Community College. I authorize the release of information to include any records or documentation that verifies my disability to ACCESS staff. I further give my permission to ACCESS 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 ACCESS 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.

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)

Already registered. I am registered to vote at my current residence address.

Yes. I would like to register to vote. (Please contact ACCESS@barstow.edu to get information on how to obtain a voters Registration form)

No. I do not want to register to vote.

Signature and Date

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
agency.
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 www.sos.ca.gov.

ACCESS Intake Form/Voters Preference Registration Form

Voters Preference Registration

Main Campus

Fort Irwin Campus