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Thank you for your interest in the Disability Resource Center! We serve students with both temporary and permanent needs. If you are unable to access any content on this form, please contact John Lee (
jlee245@calpoly.edu
) for assistance.
* Please use your Cal Poly email address (if available) for improved communication. *
If you are not using a Cal Poly approved E-Mail address, be sure to check your 'junk/spam' folders for missing communication.
Personal Information
What term will you begin at Cal Poly DRC
*
:
Select One
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
2026 - Winter
2026 - Spring
2026 - Summer
2026 - Fall
2027 - Winter
2027 - Spring
2027 - Summer
2027 - Fall
2028 - Winter
2028 - Spring
2028 - Summer
2028 - Fall
2029 - Winter
2029 - Spring
2029 - Summer
2029 - Fall
2030 - Winter
2030 - Spring
2030 - Summer
2030 - Fall
2031 - Winter
2031 - Spring
2031 - Summer
2031 - Fall
2032 - Winter
2032 - Spring
2032 - Summer
2032 - Fall
2033 - Winter
2033 - Spring
2033 - Summer
2033 - Fall
2034 - Winter
2034 - Spring
2034 - Summer
2034 - Fall
2035 - Winter
2035 - Spring
2035 - Summer
2035 - Fall
2036 - Winter
2036 - Spring
2036 - Summer
2036 - Fall
2037 - Winter
2037 - Spring
2037 - Summer
2037 - Fall
2038 - Winter
2038 - Spring
2038 - Summer
2038 - Fall
2039 - Winter
2039 - Spring
2039 - Summer
2039 - Fall
2040 - Winter
2040 - Spring
2040 - Summer
2040 - Fall
2041 - Winter
2041 - Spring
2041 - Summer
2041 - Fall
2042 - Winter
2042 - Spring
2042 - Summer
2042 - Fall
2043 - Winter
2043 - Spring
2043 - Summer
2043 - Fall
2044 - Winter
2044 - Spring
2044 - Summer
2044 - Fall
2045 - Winter
2045 - Spring
2045 - Summer
2045 - Fall
2046 - Winter
2046 - Spring
2046 - Summer
2046 - Fall
2047 - Winter
2047 - Spring
2047 - Summer
2047 - Fall
2048 - Winter
2048 - Spring
2048 - Summer
2048 - Fall
2049 - Winter
2049 - Spring
2049 - Summer
2049 - Fall
2050 - Winter
2050 - Spring
2050 - Summer
2050 - Fall
Note: Select when you would like to start your services.
Expected Graduation Term:
Select One
2011 - Winter
2011 - Spring
2011 - Summer
2011 - Fall
2012 - Winter
2012 - Spring
2012 - Summer
2012 - Fall
2013 - Winter
2013 - Spring
2013 - Summer
2013 - Fall
2014 - Winter
2014 - Spring
2014 - Summer
2014 - Fall
2015 - Winter
2015 - Spring
2015 - Summer
2015 - Fall
2016 - Winter
2016 - Spring
2016 - Summer
2016 - Fall
2017 - Winter
2017 - Spring
2017 - Summer
2017 - Fall
2018 - Winter
2018 - Spring
2018 - Summer
2018 - Fall
2019 - Winter
2019 - Spring
2019 - Summer
2019 - Fall
2020 - Winter
2020 - Spring
2020 - Summer
2020 - Fall
2021 - Winter
2021 - Spring
2021 - Summer
2021 - Fall
2022 - Winter
2022 - Spring
2022 - Summer
2022 - Fall
2023 - Winter
2023 - Spring
2023 - Summer
2023 - Fall
2024 - Winter
2024 - Spring
2024 - Summer
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
2026 - Winter
2026 - Spring
2026 - Summer
2026 - Fall
2027 - Winter
2027 - Spring
2027 - Summer
2027 - Fall
2028 - Winter
2028 - Spring
2028 - Summer
2028 - Fall
2029 - Winter
2029 - Spring
2029 - Summer
2029 - Fall
2030 - Winter
2030 - Spring
2030 - Summer
2030 - Fall
2031 - Winter
2031 - Spring
2031 - Summer
2031 - Fall
2032 - Winter
2032 - Spring
2032 - Summer
2032 - Fall
2033 - Winter
2033 - Spring
2033 - Summer
2033 - Fall
2034 - Winter
2034 - Spring
2034 - Summer
2034 - Fall
2035 - Winter
2035 - Spring
2035 - Summer
2035 - Fall
2036 - Winter
2036 - Spring
2036 - Summer
2036 - Fall
2037 - Winter
2037 - Spring
2037 - Summer
2037 - Fall
2038 - Winter
2038 - Spring
2038 - Summer
2038 - Fall
2039 - Winter
2039 - Spring
2039 - Summer
2039 - Fall
2040 - Winter
2040 - Spring
2040 - Summer
2040 - Fall
2041 - Winter
2041 - Spring
2041 - Summer
2041 - Fall
2042 - Winter
2042 - Spring
2042 - Summer
2042 - Fall
2043 - Winter
2043 - Spring
2043 - Summer
2043 - Fall
2044 - Winter
2044 - Spring
2044 - Summer
2044 - Fall
2045 - Winter
2045 - Spring
2045 - Summer
2045 - Fall
2046 - Winter
2046 - Spring
2046 - Summer
2046 - Fall
2047 - Winter
2047 - Spring
2047 - Summer
2047 - Fall
2048 - Winter
2048 - Spring
2048 - Summer
2048 - Fall
2049 - Winter
2049 - Spring
2049 - Summer
2049 - Fall
2050 - Winter
2050 - Spring
2050 - Summer
2050 - Fall
Note: Select when you plan to graduate.
First Name
*
:
Last Name
*
:
Middle Name:
Optional: Preferred Name:
EMPLID
*
:
Note: Go to your Poly Portal, click on the Personal Info tab. You will see your Poly EMPLID on the right.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Personal Pronouns:
Select One
he, him, his, his, himself
Not specified
per, per, pers, pers, perself
she, her, her, hers, herself
they, them, their, theirs, themself
ve, ver, vis, vers, verself
ze/zie, hir, hir, hirs, hirself
Contact Information
Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address
*
:
Preferred Address
Address
*
:
City
*
:
State
*
:
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Wyoming
International
Zipcode
*
:
Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address
Same as Local Address
Address:
City:
State:
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Wyoming
International
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
Primary Disability
*
:
Select One
=== General Category ===
Acquired Brain Injury
ADHD
Autism/Asperger/PDD
Blind
CRCO (Administrative Use Only)
Deaf
Hard of Hearing
Health Imp.
Learning Disabled
Long COVID-19
Mobility
Other
Psychological
Temporary Dis
Visual Impairments
Secondary Disability(ies)
General Category
Acquired Brain Injury
ADHD
Autism/Asperger/PDD
Blind
CRCO (Administrative Use Only)
Deaf
Hard of Hearing
Health Imp.
Learning Disabled
Long COVID-19
Mobility
Other
Psychological
Temporary Dis
Visual Impairments
Other Disability or Note:
Seeking Degree:
Select One
Certificate
Masters Degree
Ph.D. Degree
Post Baccalaureate
Undergraduate
Affiliation(s)
Affiliation(s)
CP Scholar
DOR (Department of Rehabilitation)
EOP
International
ROTC
Student Athlete
Transfer Student
TRIO
Veteran
Ethnicity(ies)
Ethnicity(ies)
African-American
Asian or Pacific Islander
European-American
Hispanic
Latinx / Chicanx
Multi-Racial
Native American
Other
Campus Location(s)
Campus Location(s)
Main
Additional Note:
Questions
Current Academic Level
*
(Selection is Required)
Freshman
Sophomore
Junior
Senior
Graduate student
Additional Note or Comment
Which Quarter were you admitted into Cal Poly
Why are you seeking DRC services?
Do you use a mobility device? (e.g. scooter, wheelchair, crutches)?
*
(Selection is Required)
Yes
No
Additional Note or Comment
Do you have any housing and/or parking disability - related needs?
Have you received accommodations in the past? If so, please describe below (e.g. Extended testing time of 1.5 in high school)?
I am comfortable advocating for my disability-related needs
*
(Selection is Required)
Strongly disagree
Disagree
Somewhat disagree
Somewhat agree
Agree
Strongly agree
Additional Note or Comment
Do you identify as a non-traditional student? (e.g. first generation college student, low income, BIPOC, 25+, parent)
*
(Selection is Required)
Yes (Specify Below)
No
Additional Note or Comment
Under the Voter Registration Act (NVRA) of 1992, DRC is an Agency-Based Registration Site, where students have the opportunity to become registered voters during the application process. There is no obligation to register to vote and the student's decision will have no effect on services offered by DRC.
If you do not check a box you will be considered to have decided not to register to vote at this time.
If you would like help in filling out the voter registration application, we will help you. The decision whether to seek or accept help is yours. You may fill out the application in private.
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference you may file a complaint with:
Secretary of State Elections Division 1500 11th Street Sacramento, CA 95814.
Telephone: (916) 653-6814
Already Registered. I am registered to vote at my current residence address.
Yes. I would like to register to vote. (you may click
here
or request paper copy during intake meeting)
No. I do not wish to register to vote.
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