Request for Disability Services

 In order to process your request, please print this form out and fill it out.  You may   either e-mail it to gluke@shastacollege.edu or take it to the DRC Office in Room 1310 on campus.

Date of request:                    
Name:SSN#
Mailing Address:
City:StateZip
Phone Number:E-mail Address:

Please check one of the following that apply to you.  If more than one apply, please include it in the description of your disabilities. 

I would like to have an appointment with the Counselor for students with Disabilities

I may have a learning disability and would like a pre-assessment with the LD Specialist.
Describe your disability:
Describe your limitations:

In order for us to provide support services in your academic classes, we must have verification of your disability from a physician, psychologist, psychiatrist, therapist or other professional such as an audiologist. 
Please bring this documentation to your FIRST appointment with the counselor for students with disabilities or the LD Specialist. You may make this appointment by calling the DRC Office at (530)225-3973.

Shasta College