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 Rainsville, Alabama 35986      256-638-4418 or 256-228-6001

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Disabilities: Information Release Form 

Print, fill out, and bring or mail to the ADA/504 Coordinator.

Students with Disabilities home

Impairment and Disability Assessment

Individual Postsecondary Plan

Release of Information

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:		  

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:		  

SIGNATURE:		  

 
 
 

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Copyright  ▪  Northeast Alabama Community College ▪  P. O. Box 159, Rainsville, Alabama 35986
(256) 638-4418 or (256) 228-6001