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Online Student Application

Two easy steps to register
Welcome to the Disability Accommodations & Support Services (DASS) at California State University Channel Islands (CSUCI). We are committed to providing you with an accessible educational experience.

Procedure for New Students Requesting Services/Accommodations:

1. Complete the application form below in its entirety
2. Submit documentation from external or third party sources (documentation must be uploaded online, faxed to 805-437-8529, or submitted in-person at Arroyo Hall 210

Documentation from external or third party sources may include:

  • Educational or medical records, reports and assessments created by health care providers, school psychologists, teachers, or the education system
  • NOTE: If you do not have any documentation from external or third party sources, you must complete and submit this Self-Report form: http://www.csuci.edu/dass/documents/self-report-form.pdf. However, if the nature and extent of the disability is not evident, some form of documentation from external sources is typically needed.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  7. Hint: Enter 9 alpha numeric characters.
  8. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
Local Address
  4. Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address

  4. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  2. Secondary Disability(ies)

    General Category

  5. Affiliation(s)
  6. Ethnicity(ies)
  7. Campus Location(s) *

Questions

  1.  
    Native Language * (Selection is Required)
  2.  
    Enrollment Type * (Selection is Required)
  3.  
    Current Semester * (Selection is Required)
  4.  
    Class Level * (Selection is Required)
  9.  
    Have you received accommodations in the past: * (Selection is Required)
  11.  
    Do you have documentation? * (Selection is Required)
  12.  
    Do you use any mobility aids, disability aids, or equipment? * (Selection is Required)
  13.  
    Are you currently seeing a psychiatrist, therapist, or counselor? * (Selection is Required)
  14.  
    If No, would you like to receive information regarding Counseling and Psychological Services (CAPS)? * (Selection is Required)
  15.  
    Are you a client of the following agencies? If yes, please provide their contact information in the additional notes area.
  16.  
    Important Voter Registration Information: By checking each box below, you are acknowledging that you read these important notices:
  17.  
    Would you like to register to vote? * (Selection is Required)
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