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Disabilities: Information Release Form |
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Print, fill out, and bring or mail to the ADA/504 Coordinator. |
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RELEASE OF INFORMATION
1. I give the ADA/504 Coordinator permission to
issue letters/memorandums to my
instructors informing them that I am a student with
a disability and need special
accommodations.
NAME (Please print):
____________________________________________
DATE:
________________________________________________________
STUDENT NUMBER/SSN:
_______________________________________
SIGNATURE:
__________________________________________________
2. I further agree that the ADA/504 Coordinator may
discuss my disability with my
instructors if they request further information.
NAME (Please print):
____________________________________________
DATE:
________________________________________________________
STUDENT NUMBER/SSN:
_______________________________________
SIGNATURE:
__________________________________________________
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