Scribd
Upload
12 views1 page

Consent Form

Consent form Dallas college

Uploaded by

kgracereeder
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
12 views1 page

Consent Form

Consent form Dallas college

Uploaded by

kgracereeder
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

ACCESSIBILITY SERVICES

[email protected]
972.6696400, X2565

CONSENT FOR RELEASE OF INFORMATION

I (student name), _________________________________ Student ID#_________________

Address:_________________________________ City:________________ Zip:___________

Date of Birth:______________________ Preferred Phone#_____________________________

I authorize Accessibility Services to release information to college personnel (instructors, success


coaches, program specialists, interpreters, etc.) from my student record (class schedule, courses
completed, GPA, financial aid information, etc.), which may or may not include information about my
disability, for purposes of preparing/providing educational services I might need.

In addition to college personnel, I authorize release of the above information to the individuals specified
below:

Please print clearly. List each authorized person and relationship to student:

Release to ________________________Relationship to student


Release to ________________________Relationship to student
Release to ________________________Relationship to student
Release to ________________________Relationship to student

OTHER (Please specify) -______________________________________________

This release will remain in effect until the student revokes it in writing.

___________________________________ ________________________
Print Name Student ID#

___________________________________ ________________________
Signature of Student Date

__________________________________ ________________________
Signature of Person Informing Date

You might also like