Student Consent/Release of Information Form

Access and Disability Services

STUDENT CONSENT/RELEASE OF INFORMATION FORM

Please initial after each paragraph to indicate that you understand the ADS procedure specified and to give ADS permission to act in accordance with such procedures.

I,______give permission to the Access and Disability Services Office to contact my clinician and/ or diagnostician in order to clarify my condition and associated needs, thus helping ADS to determine appropriate adjustments or accommodations.

I understand that the above information will be used by ADS, in conjunction with University policies, to assess and implement as appropriate, my request for adjustments or accommodations related to academic and other University-sponsored programs.

Initials______

In the event that I am requesting adjustments or accommodations of any kind in a course, I agree to distribute to that course’s faculty (in a timely manner) the letter written by ADS outlining the recommended adjustments or accommodations; or if the course is outside the Graduate School of Education, abide by their policies with regard to making course and examination arrangements.

I understand that the failure to provide requested information related to my need for accommodations (or failure to do so with adequate time) may result in the course’s inability to accommodate my needs at that time.

Initials______

I authorize ADS to communicate with key individuals (faculty and administrators) to further clarify their ability to provide necessary assistance by implementing the recommended adjustments or accommodations. Such communication, however, will not include confidential diagnostic or clinical information. However, I understand that I may wish to provide additional information at my discretion. I understand that it is my responsibility to discuss my needs directly with faculty, but that ADS will supplement this communication in the event that further clarification is needed.

Initials______

I understand that I may amend or revoke ADS’s authorization to act on my behalf at any time through written request, even if such action limits ADS’s ability to act on my behalf.

Initials______

Student SignatureDate

Signature of Eileen Berger, Assistant Director, Office of Student Affairs, Access & Disability Services Administrator