DESP Disability Verification Form

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Student Information

I am requesting that you provide verification of my disability and limitations in order for me to receive disability-related services at West Valley College.

Student Name*

First Name

Last Name

Birthdate*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Student ID Number*

Enter the numbers after G0

Student Diagnostic Information

Current Diagnosis*

Condition is:*

Permanent Observable Stable Prone to Exacerbation Temporary Duration

Please specify duration.

Please describe how the condition substantially limits major life activities.

Add another diagnosis

Yes No

Student Diagnostic Information - 2

Current Diagnosis*

Condition is:*

Permanent Observable Stable Prone to Exacerbation Temporary Duration

Please specify duration.

Please describe how the condition substantially limits major life activities.

Professional Provider Information

Provider Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

License Number*

I understand that the information provided by the verifying professional will become part of the student record, and may be released to the student upon written request.

I agree I disagree

Provider Signature

[clear]

Use your mouse or finger to draw your signature above

The Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services provided by the Disability and Educational Support Program (DESP). Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the Chancellor’s Office of the California Community Colleges or other state or federal agencies: however disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99.) The information on this form is being collected pursuant to California Education Code Sections 66701, 67310-67312, and 84850 and California Code of Regulations, Title 5, Section 56000 et seq.