ACCESSIBILITY SERVICES
DSSO@dcccd.edu
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
