Online Student Application

College of the Siskiyous provides educational services and access for eligible students with documented disabilities who intend to pursue coursework at College of the Siskiyous. A variety of programs and services are available which afford eligible students with disabilities the opportunity to participate fully in all aspects of college programs and activities through appropriate and reasonable accommodations.

Completion of this form constitutes an agreement to apply for Disability Services (DS).

Student Responsibilities:

- I will provide DS with the information, documentation, and/or forms (medical, educational, etc.) deemed necessary by DS to verify my disability(ies).

- I will meet with the DS Director/Counselor to complete an Academic Accommodation Plan (AAP) and agree to meet with the Director/Counselor each semester to update the AAP .

- I will utilize DS services in a responsible manner. I understand that DS uses written service provision policies and procedures that must be adhered to for the continuation of services.

- I will comply with the Student Code of Conduct adopted by the college.

- I understand those policies and procedures are available to me on the DS website under "DS Student Handbook", or can be mailed to my physical address upon request.

If you are unable to access any content on this form or have questions, please email ds@siskiyous.edu for assistance.

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID:
Hint: Enter 9 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender *:
Pronouns:

Contact Information

Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address *:

Local Address

Address *:
City *:
State *:
Zipcode *:
Hint: Enter zipcode as 97331 or 97331-0000.

Permanent Address

Same as Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Additional Information

Important Notices for National Voter Registration

1. Applying to register or declining to register to vote will NOT affect the amount of assistance that you will be provided by Disability Services (DS).

2. If you would like help in filling out the voter registration form, we will help you. The decision of 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 following website for the Secretary of State’s website at https://www.sos.ca.gov.

The information contained in this application is as accurate as possible. This confidential information may be shared on my behalf with State Center Community College District Disabled Students Programs and Services personnel who are directly involved with the DS program. After completing the intake process with the DS program, my connection to the DS program will be visible in the Starfish Student Success Platform only to those State Center Community College District Personnel that have a legitimate educational interest related to my support network.

Full Name for Electronic Signature:

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