Page 1 of 6
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SERVICES TO STUDENTS WITH DISABILITIES
6000 J Street, Sacramento, California 95819-6042
Telephone (916) 278-6955
Fax (916) 278-7239
TDD (916)278-7239
APPLICATION FOR STUDENT SUPPORT SERVICES
Contact Information
Instructions: All applicants must complete this section.
State ID #:
Full Name:
Street Address:
City:
State:
Phone Number(s):
Home #:
Cell #:
Email:
Zip:
Enrollment
Instructions: All applicants must complete this section.
Have you applied for SSWD services before at Sacramento State?
Enrollment Type:
Semester:
Major:
Class Level:
Semester and year entered Sacramento State:
Catalog Rights:
Transferring from:
City:
State:
Rev. 11/2015
Yes
No
Page 2 of 6
Placement Tests
Instructions: Please check all placement tests that apply and enter score
ELM Taken: Score:
EPT Taken: Score:
WPJ Taken: Score:
Personal Information
Instructions: All applicants must complete this section. Please select all that apply.
Ethnicity:
Asian
American Indian or Alaska Native
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Date of Birth:
Gender:
Male
Female
U.S. Citizen/Permanent Resident:
Yes
Native language other than English:
Primary Disability:
Other Disabilities:
Other Disabilities:
Permanent
Permanent
Permanent
No
Temporary
Temporary
Temporary
What support services are you requesting?
Instructions: All applicants must complete this section. Please select all that apply
Disability Related Counseling:
Sign Language Interpreter
Reader
Notetaker
Rev. 11/2015
Academic
Career
Personal
Grad school
Page 3 of 6
Tutoring Resources
Test Accommodations
Course Accommodations
Cart Services
Captioner
Financial Aid Resources
Financial Literacy Resources
Assistive Computer Training
Alternative Formats
Other:
Do you use any of the following aids?
Instructions: All applicants must complete this section. Please select all that apply.
White Cane
Guide Dog
Service Dog
Walker
Cane
Crutches/Braces
Braille
Special Optical Devices
Manual Wheelchair
Electric Wheelchair/Scooter
Respirator
Prosthetics:
Arm
Leg
Other Aids (please specify):
Do you receive the following financial support?
Instructions: All applicants must complete this section. Please select all that apply.
CalWORKS
Veteran Benefits
Family Support
Rev. 11/2015
Page 4 of 6
Self-Support
Social Security Disability Insurance
County General Assistance
Supplemental Security Income (SSI)
Financial Aid: (please specify):
CHART 1: TRIO family size to income level for 2015
Size of
Family
Unit
1
2
3
4
5
6
7
8
TRIO Low
Income Level
for 2015
$17,655
$23,895
$30,135
$36,375
$42,615
$48,855
$55,095
$61,335
END CHART 1
Based on this chart above do you qualify as low income?
Yes
No
If you have not applied for financial aid, do you need help with the FAFSA Free
Application for Federal Student Aid?
Yes
No
Are you served by these Sacramento State offices?
Instructions: All applicants must complete this section. Please select all that apply.
Educational Opportunity Program (EOP)
College Assistance Migrant Program (CAMP)
Veterans Success Center
Peer & Academic Resources Center
McNair Scholars
Guardian Scholars
Rev. 11/2015
Page 5 of 6
Other (please specify):
Are you a client of the following agencies?
Instructions: All applicants must complete this section. Please select all that apply.
Cal. State Dept. of Rehabilitation
U. S. Dept. of VA Rehabilitation
Private Rehabilitation
Workman’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 needed to be considered for supplemental services under the
federally funded TRIO Student Support Services program. All information will be
treated as confidential.
*Social Security #
Student Signature
Rev. 11/2015
-
Date
Page 6 of 6
End of application
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):
Rev. 11/2015