Fillable Student Services Plan Request (California)

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Student Services Plan Request (California)

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The Student Services Plan Request (California) form is 2 pages long and contains:

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  • 35 check-boxes
  • 45 other fields

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File type: PDF

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DEPARTMENT OF REHABILITATION STATE OF CALIFORNIA
Student Services Plan Request
DR 203 (REV 08/19)
Page 1 of 2
I give permission to school personnel to release this information to the Department of Rehabilitation.
(20 U.S.C. 1232g(b) and 34 CFR 99.30 and 99.31.) I confirm that the student has documentation of or
is regarded as having the disability stated above. I give consent for the student to participate in student
services provided or arranged by the DOR, for as long as the student qualifies for such services.
Student Signature
Date Signed
Parent/Guardian/Conservator Signature
Date Signed
Student Last Name
First Name
Middle Initial
Mailing Address
City
County
Phone Number
Email Address
Date of Birth (mm/dd/yyyy)
Social Security Number (if available)
Gender Male Female
Decline to State
Please check all that apply
White Hispanic or Latino Black or African American American Indian or Alaska Native
Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander
Chinese Korean Asian Indian Japanese Vietnamese
Filipino Laotian Cambodian Other Asian Decline to State
Please state the student’s disability or reason
for IEP/504 eligibility:
Documentation (please select one)
IEP (provide a copy)
504 Plan (provide a copy)
School Signature (see below)
If “School Signature” is selected: I confirm that the student is enrolled in the school identified below
and has a record of or is regarded as having the disability stated above.
Signature of School Official: Date:
Printed Name of School Official: Title:
School Name
School Address
Current Grade Level
School Type
Public Private Charter Home school GED program
Vocational/Technical College/University Other
Expected Date of Graduation/Exit
from School (mm/dd/yyyy)
Parent/Guardian/Conservator Last Name
First Name
Relationship
Parent
Guardian
Conservator
Phone Number
Email Address
DEPARTMENT OF REHABILITATION
STATE OF CALIFORNIA
Student Services Plan
DR 203 (REV 08/19)
Page 2 of 2
FORM PURPOSE
This form is intended to request the Student Services Plan for potentially eligible students, in
accordance with 34 CFR 361.48(a) and the Vocational Rehabilitation Services Portion of the Unified
State Plan. “Potentially eligible” students are defined as students with disabilities, ages 16 through 21,
who have not yet applied or been found eligible for the vocational rehabilitation program. This is not an
application for vocational rehabilitation services.
The Student Services Plan can include any or all of the five pre-employment transition services: job
exploration counseling, work-based learning, postsecondary enrollment counseling, work readiness
training, and instruction in self-advocacy, depending on the needs and interests of the student. The
Student Services Plan supports students to explore and prepare for employment through career
exploration, work experience, and other foundational skills that assist in achieving workplace success.
FORM COMPLETION INSTRUCTIONS
Complete this form to document that the student is currently enrolled in a recognized education
program and is considered a student with a disability as defined in 34 CFR 361.5(c)(51).
Parent/Guardian contact information and consent are required for students who are less than 18
years of age and not an emancipated minor. Conservator contact information and consent are
required for students with disabilities who are over 18 and have a conservator with relevant authority.
An electronic version of this form is available online at www.dor.ca.gov. For more information on the
requirements for pre-employment transition services, refer to 29 USC sections 705(37) and 733, and
34 CFR parts 361.48(a) and 361.5(c)(51). Consent for the student to participate in the Student
Services Plan may be revoked at any time by providing written notice to the local DOR office.
NOTICE AND PRIVACY STATEMENT
The information requested on this form is necessary to correctly identify the individual as a student
with a disability as defined in 34 CFR 361.5(c)(51), to provide authorization for the provision of pre-
employment transition services, and to provide authorization for school personnel to release the
information requested on this form to the DOR to coordinate, provide, or arrange student services in
accordance with 29 USC sections 705(37) and 733 and 34 CFR parts 361.48(a) and 361.5(c)(51).
The Social Security Number, if available, is necessary to utilize the Social Security Administration’s
Ticket to Work and other programs, and also to provide some services. Failure to provide the
information requested may result in delays in services. Individuals should not provide any personal
information on this form that is not requested.
The student, or parent, guardian, or conservator as appropriate, has the right to revoke the school’s
authorization to release information by providing written notice to school personnel. If the student, or
parent, guardian, or conservator as appropriate, revokes the authorization, it will not affect information
released to the DOR before the school personnel received the written notice revoking the authorization.
An individual has the right to inspect information maintained by the DOR about the individual, unless
otherwise prohibited or conditioned by law or regulation. For assistance accessing such information,
contact the DOR. The DOR’s Privacy Policy is online at www.dor.ca.gov. The DOR office locations
and contact information can be found at https://www.dor.ca.gov/Home/FindAnOffice.
Any personal information maintained by the DOR is subject to the limitations in the California
Information Practices Act (Civ. Code § 1798 et seq.), Title 34 Code of Federal Regulations section
361.38, and California Code of Regulations, title 9, sections 7140 through 7143.5. The DOR may
release personal information in response to a court order, investigations in connection with law
enforcement, fraud, or abuse, subject to the limitations set forth in California Code of Regulations, title
9, section 7143.5. (34 CFR 361.38(e)(4) and (5).)
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Student Services Plan Request (California)

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Completed 13 June 2021

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