Santa Monica College
DISABLED STUDENT PROGRAMS & SERVICES
LEARNING DISABILITIES PROGRAM
INITIAL APPLICATION FOR SUPPORT SERVICES
DATE OF APPLICATION FOR SERVICES ____________________
NAME ____________________________________________________________ SMC ID# _______________________________
Last
First
Middle
ADDRESS___________________________________________________________________________________________________
Street
Apt#
City
TELEPHONE ______________________________________
State
Zip Code
CELLPHONE ______________________________________
EMAIL ___________________________________________________________
VETERAN Yes
DATE OF BIRTH____________________________
EDUCATIONAL GOAL: AA Degree
Transfer
Certificate
No
Other _________________
CAREER GOAL _______________________________________ MAJOR ___________________________________________
REFERRAL: Who referred you to our program? ____________________________________________________________
Reason for referral_________________________________________________________________________
NATURE OF DISABILITY
Age of Onset: ____________
Medication______________________________________________________________
(Optional)
MOBILITY
SPEECH
HEALTH
___ Amputation
__ Speech Disorder
___ Arthritis
___ Cerebral Palsy
___ Cardiac Disorder
___ Hemiplegia
LEARNING
___ Epilepsy
___ Paraplegia
__ Learning Disability
___ HIV/AIDS
___ Quadriplegia
__ Intellectual Disability
___ Other______________
___ Orthopedic Condition
PSYCHOLOGICAL
VISION
___ Postpolio Syndrome
___ Psychological Disorder
___ Partially Sighted
___ Repetitive Motion Syndrome
___ Substance Abuse
___ Blind
ACQUIRED BRAIN INJURY
OTHER
HEARING
___ Traumatic Brain Injury
___ ADD
__ Hard Of Hearing
___ Stroke
___ Autism/Asperger
__ Deaf
___ Brain Tumor
___ Other _______________
___ Multiple Sclerosis
___ Other______________
___ ADHD
LD Application 06/15
Educational History
1. Highest Grade Completed (Please circle your response):
2. Degrees Achieved:
7
8
9
10
11
12
13
14
15
________________________________________________________________________________
3. Name of last school you have attended: ______________________________________________________________________
Name of School
4. Last semester’s classes:
________________________
________________________
________________________
________________________
City. State
Grade
_____
_____
_____
_____
Date Last Attended
Instructor
___________________
___________________
___________________
___________________
5. Current classes:
________________________
________________________
________________________
________________________
Instructor
___________________
___________________
___________________
___________________
6. Describe any difficulties you are having in these classes:
7. In what classes have you done well?
8. Have you ever been tested for Special Education?
Yes
No
What grade?_______
9. In elementary school do you remember having trouble with: (please explain if possible)
Learning to read?
Spelling?
Math?
10. Is there a history of learning disabilities in your family?_____________________________________________________
11. Do you have any physical disability that inhibits academic performance? (Please explain)
____________________________________________________________________________________________________
12. Have you ever been treated for psychological or emotional problems?_________________________________________
____________________________________________________________________________________________________
13. Is English your 1st language? Yes
No
If not, what is? ___________________________
When did you first learn to speak English?_______________________________________________
LD Application 06/15
14. Rate the level of difficulty for each of the following:
_____English
_____Math
_____Sciences
_____Foreign Language
(1 - very easy,
_____Textbook reading
_____Memory
_____Organization
_____Note-taking
2 - moderate,
3 - very difficult)
_____Spelling
_____Essay writing
_____Test-taking
15. Please explain any rating of 3:
16. How do you compensate for the difficulties you experience?
17. Have you repeated any classes? Which ones?
18. For us to better understand you, please describe the problems you have been having at SMC and in your past learning.
Please use this opportunity to tell us anything we should know about you in order to make recommendations.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Emergency Contact Person
1. Name of person to notify in case of an emergency: _____________________________________________________________
Relationship to you: ________________________________________
Telephone: ___________________________________
I agree that if necessary for medical or educational purposes, or if necessary for the safety of myself, or others,
information about me may be released to, or obtained from an instructor, relevant agency, or family member. I
understand that information contained in my file will be available to the California Community College
Chancellor's Office if they request it for an audit, a program evaluation, or educational research.
Signature: _________________________________________________________________ Date:_______________________
LD Application 06/15
FOR OFFICE USE ONLY
Recommendations
Learning disabilities assessment:
Coursework:
Study strategies:
Tutorial:
Comments:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
LD Specialist________________________________
LD Application 06/15
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