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Intake Form
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Student Information
Please enter your information
First Name
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Last Name
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Middle Name
Gender / preferred pronouns:
W Number (Example: W10123456)
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Student Email
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Please use your Chabot College issued email address (I.E.: Zonemail)
Student's Phone:
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What is your major of educational objectives at Chabot College?
Accessibility Request Information
Disability or Limitation?
Have you ever received services from DSPS at Chabot College?
Required
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Have you ever received services from DSPS at Chabot College?
Yes
Have you ever received services from DSPS at Chabot College?
No
Are you a current high school student?
Are you a current high school student?
Yes
Are you a current high school student?
No
Are you a client of State Department of Rehabilitation?
Required
*
Are you a client of State Department of Rehabilitation?
Yes
Are you a client of State Department of Rehabilitation?
No
Rehabilitation Counselor's Name:
Are you a client of Regional Center of East Bay?
Are you a client of Regional Center of East Bay?
Yes
Are you a client of Regional Center of East Bay?
No
Counselor's Name:
Have you applied for financial aid through FAFSA or the California College Promise Grant fee waiver?
(formerly the BOG fee waiver)?
Have you applied for financial aid through FAFSA or the California College Promise Grant fee waiver?
Yes
Have you applied for financial aid through FAFSA or the California College Promise Grant fee waiver?
No
Are you a part of other special programs at Chabot?
Are you a part of other special programs at Chabot?
Yes
Are you a part of other special programs at Chabot?
No
If yes, please include name of program:
(Aspire, CalWORKS, CARE, EOPS, Excel, Guardian Scholars, MESA/Trio STEM, PACE, Puente, Umoja, RISE, Movement or Veterans)
Have you attended any other college besides Chabot College?
Have you attended any other college besides Chabot College?
Yes
Have you attended any other college besides Chabot College?
No
If yes, have you received assistance from Disabled Student Services at that college?
If yes, have you received assistance from Disabled Student Services at that college?
Yes
If yes, have you received assistance from Disabled Student Services at that college?
No
College:
Qtr/Sem & Year:
Accommodations/Services?
Are you a continuing student?
Are you a continuing student?
Yes
Are you a continuing student?
No
What semester will you begin or resume classes? (for example: Spring 2024)
Are you taking classes at Las Positas College? If so, do you give us permission to share disability verification with them?
Are you taking classes at Las Positas College? If so, do you give us permission to share disability verification with them?
Yes
Are you taking classes at Las Positas College? If so, do you give us permission to share disability verification with them?
No
Upload supporting document(s)
Documentation can also be dropped off at our office or faxed to us at 510.723.7200.
E-Signature:
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Document Information
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