CaliforniaStateUniversity, Sacramento
Services to Students with Disabilities
6000 J Street, Sacramento, California95819-6042 ♦ (916) 278-6955 ♦ (916) 278-7825 FAX ♦ (916) 278-7239 TDD
Application for Student Support Services
[Confidential]
Name: Sac State ID #:
(first) (middle) (last)
Address CityStateZip Code
Phone(s):Home #:()- Cell #: ( ) - Email:
Have you applied for SSWD services before at Sacramento State?YesNo
Enrollment Type: ProspectiveRegular Open UniversityCollege of Continuing Ed.
Semester: Fall Spring Summer Year: 20
Major: Class Level: Fr.Soph.Jr.Sr. Grad.
Semester and year entered Sacramento State: Catalog Rights:
Transferring from:
Name of InstitutionCityState
Ethnicity: Asian American Indian or Alaska Native Black or African American
(check all that apply)Hispanic or Latino Native Hawaiian or Pacific Islander White
Gender: MaleFemaleDate of Birth: / /
U. S. Citizen/Permanent Resident: YesNo Native language other than English:
ELM Taken: Score: EPT Taken:Score: WPJ Taken: Score:
Primary Disability:PermanentTemporary
Other Disabilities:PermanentTemporary
PermanentTemporary
FOR SSWD STAFF/OFFICE USE ONLY
(SSWD Counselor/Director: Initial and Date each applicable item)Primary Counselor Disability Certification Date:
Disability Code(s):LD Certification Date:
SSS Eligible(34 CFR,646.3):
This document is available in alternate formats upon request.
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What support services are you requesting?
Disability Related Counseling:Sign Language Interpreter Captioner
Academic Alternative Formats (e.g. E-text)
CareerReader
PersonalNotetaker
Grad SchoolTutoring Resources
Test AccommodationsFinancial Aid Resources
Course Accommodations Financial LiteracyResources
Cart ServicesAssistive Computer Training
Other:
Do you use any of the following aids?
White Cane Braille Manual Wheelchair
Guide Dog Special Optical Devices Electric Wheelchair/Scooter
Service Dog Prosthetics: Arm Leg Respirator
Walker Cane Crutches/Braces Other Aids (please specify):
Size of Family Unit / TRIO Low Income Level for 20151 / $17,655
2 / $23,895
3 / $30,135
4 / $36,375
5 / $42,615
6 / $48,855
7 / $55,095
8 / $61,335
Do you receive the following financial support?
CalWORKsSocial Security Disability Insurance
Veteran BenefitsCounty General Assistance
Family Support Supplemental Security Income (SSI)
Self SupportFinancial Aid: specify
Based on this chart do you qualify as low income? Yes No
Do you need help with the Free Application for Federal Student Aid?
Yes No
Are you served by these Sacramento State offices?
Educational Opportunity Program College Assistance Migrant ProgramGuardian Scholars Veterans’Success Center Peer & Academic Resource Center McNair Scholars
Other: (please specify):
Are you a client of the following agencies?
Cal. State Dept. of RehabilitationPrivate Rehabilitation
U. S. Dept. of VA RehabilitationWorkman's Compensation
Rehabilitation Counselor/Agency Name:Phone:( ) -
Location: Email:
VERIFICATION OF INFORMATION/ CONFIDENTIALITY STATEMENT:
By signing this application, I attest that all the information on this application is true. I hereby give permission for the SSWD professional staff to release or obtain information to or from other professionals (on & off campus), relevant to the impact of my disability on my education, in order to assist me in the pursuit of my educational/career goals. This authorization shall remain in effect during my enrollment at Sacramento State or until revoked in writing by me.Further I understand that SSWD will review my transcript and financial aid information to help determine appropriate services, eligibility for grant aid, and to track academic progress. I understand that SSN and other demographic information is not required for SSWD eligibility and accommodations, but is neededto be considered for supplemental services under the federally funded TRIO Student Support Services program. All information will be treated as confidential.
Social Security #:-- _
Student SignatureDate
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