1
Revised: 11/03/22
A.R.C. Application for Services
Date:
Student Name:
Preferred Name:
E-mail Address:
Student ID:
Pronouns:
Phone #:
DISABILITY INFORMATION (required)
1. What is your Primary Disability?
2. What is your Secondary Disability? (if applicable)
3. What will you submit to the A.R.C. as Verification of Disability? This is required. You must include your
Verification of Disability documentation in order for your Application to be complete.
High School IEP or 504 Plan
College/University Records
Health Records
Doctor/Provider Letter
If you do not have any of the documentation listed above, you can ask your licensed provider or certified
professional to complete a Verification of Disability form. A.R.C. Verification of Disability form.
Verification of Disability form
4. In your own words, describe how your disability effects your education and learning:
Medication or Prescription
Agency Records (i.e. VA, Dept. of Rehab, Regional Ctr.)
Other:
2
Revised: 11/03/22
EDUCATION INFORMATION (required)
5. What is your major and educational goal? If undecided, write “undecided”.
Major (or Area of Study):
Educational Goal:
Certificate
Associate Degree
Associate Degree for Transfer (AA-T, AS-T)
Transfer
Personal Enrichment
Other:
6. What is your career goal?
7. On a scale of 1-5, how confident are you with your major/area of study, educational goal, and career goal?
(Check one rating for each area)
Not Confident
1
2
3
4
5
Very Confident
Major/Area of Study:
Educational Goal:
Career Goal:
8. On a scale of 1-5, do you feel supported and encouraged in your education? (Check one)
Not Supported/Encouraged
1
2
3
4
5
Very Supported/Encouraged
Who supports and encourages you? (Check all that apply)
Counselors
Instructors/Professors
Other:
Self
Family
Friends
BASIC NEEDS ASSESSMENT
9. What is your current source of income? How do you pay for college (i.e. tuition, books, school supplies, etc.)?
(Check all that apply)
Financial Aid (Pell Grant, CCPG/BOG-FW)
Scholarships
Full-time work (40+ hours/week)
Public assistance/public agency
Grossmont College Promise (2-years free tuition)
Family support (parents, spouse, etc.)
Part-time work (less than 40 hours/week)
Other:
10. Is this your first semester at Grossmont College and are you interested in FREE tuition for your first 2-years
through the Grossmont-Cuyamaca College Promise?
Yes No
3
Revised: 11/03/22
11. What is your current housing situation? (Check all that apply)
House/apartment alone or roommate(s)
Car/vehicle
Unstable housing (i.e. couch surfing)
House/apartment with family/spouse/partner
Shelter or other temporary housing
Other:
12. What is your current primary method of transportation to campus? (Check all that apply)
Car/vehicle–drive myself
Car/vehicle–ride with friends/family
Ride share (Uber, Lyft, etc.)
Public transportation
Walk to campus
Other:
13. Do you have enough food to eat? (Check one)
Yes No
Sometimes
14. On a scale of 1-5, what is your current stress level? (check one)
Low Stress
1
2
3
4
5
High Stress
☐ ☐ ☐ ☐ ☐
15. How do you manage your stress?
16. In the last two weeks, have you had thoughts of suicide? (Check one)
Yes No Not Sure
17. List any other student service programs in which you participate at Grossmont College.
18. Do you currently participate in any of the following community agencies/programs? (Check all that apply)
CalFresh/SNAP
Social Security (disability income)
Department of Rehabilitation (DOR)
San Diego Regional Center (SDRC)
Veterans Affairs (VA)
Other:
Submit your completed A.R.C. Application for Services, Service Agreement, and Verification of Disability to the
Accessibility Resource Center (A.R.C.). E-mail to: grossmont.ARC.apply@gcccd.edu, fax to: 619-644-7980, mail to:
Grossmont College, Attention: A.R.C. Bldg. 60-120, 8800 Grossmont College Drive El Cajon, CA 92020, or visit Bldg. 60-
120.
Student’s Signature:
Date:
Revised: 11/03/22
A.R.C. Service Agreement
As a student with Grossmont College’s Accessibility Resource Center (A.R.C.), I understand:
1. Participation with the A.R.C. is voluntary and confidential. All of my personal information and
documentation with the A.R.C. remains confidential unless I authorize it to be released by signing a
Release of Information form. Participation with the A.R.C. will not be indicated on my college
transcript.
2. In efforts to coordinate and implement accommodations, services, and support, A.R.C. staff and
counselors may communicate with my instructors and other college professionals when there is an
educational need-to-know.
3. In efforts to facilitate access to services, disability documentation may be shared between
Grossmont College’s Accessibility Resource Center (A.R.C.) and Cuyamaca College’s Disabled
Students Programs and Services (DSPS) when applicable.
4. Should I choose to use my accommodations, I may dialogue with my instructors about my services
and show them my Authorized Academic Accommodations letter, but I am not obligated to do so.
5. Should I choose to use my accommodations, I may need to set-up my accommodations with the
A.R.C. by completing an online Request for Accommodations form at the beginning of each semester
or in a timely manner.
6. I can schedule an appointment to meet with an A.R.C. Counselor/Specialist for
academic/career/personal counseling and disability management. Appointments can be scheduled
online or by contacting the A.R.C. in-person, by phone, or by e-mail. Should I have an appointment
scheduled, but can no longer attend, I will reschedule or cancel my appointment.
7. Three (3) or more absences from a scheduled A.R.C. appointment or service without advanced
notice (“no shows”) in one semester, may result in a meeting with the A.R.C. Coordinator to address
excessive absences.
8. All Grossmont students are held to the same standard including satisfactory academic progress and
Code of Conduct as identified in the Grossmont College Catalog.
I have read and I understand the terms of the A.R.C. Service Agreement. By signing this document, I
am agreeing to abide by its terms.
ID#:
Student’s Name (Print):
Date:
Student's Signature:
