Disabled Student Programs and Services
REQUEST FOR PRIORITY ENROLLMENT ONLY
FOR CONTINUING STUDENTS ONLY
Name: _______________________________________________ Date: __________________________
Student number: _____________________________ Contact number: _________________________
This form is for continuing DSPS students who wish to continue their priority registration services but
do not wish to request in-class accommodations at this time.
PRIORITY REGISTRATION REQUESTED FOR: Fall Spring Summer 20_______
Do you have any updated information to provide to DSPS regarding your disability or
agency/emergency contacts? If so, please specify:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Updates to your address and/or phone number should be changed through your MyCerritos account or
in Admissions and Records.
My signature below indicates that I understand and agree to the following:
• I will need to submit a Request for Services form if I decide later that I want to request
additional accommodations.
• I will use DSPS services in a responsible manner and provide a minimum 5 days’ notice when
requesting services.
• I will uphold the student Standards of Conduct, which applies to all Cerritos College students.
• I understand that DSPS may exchange my educational information with other campus
professionals who have an educational need to know, in accordance with the Federal Family
Educational Rights and Privacy Act.
• I understand that the academic adjustments, auxiliary aids, services and/or instruction
authorized apply only at Cerritos College and may or may not be accepted at other institutions.
• I understand that I must complete a Request for Services each semester I wish to receive
services other than Priority Registration from DSPS.
Student Signature: _______________________________________________ Date: ________________
DSPS Faculty Signature: ___________________________________________ Date: ________________
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