NOVA_H_K

Disability Support Services

CONSENT FOR RELEASE OF INFORMATION

 

               

            Name _______________________________________________________________________________

                                                Last                                                         First                                                        Middle

 

                Emplid # ____________________________________ Date of Birth _____________________________

                                                                                                                                                                MM/DD/YY

 

                Maiden name or other used ______________________________________________________________

                                                                                Last                                         First                                        Middle

 

                Home Campus      AL _____ AN _____ LO _____ MA _____ WO _____

 

 

I, the undersigned, consent to and request all appropriate persons and/or agencies or institutions to release information regarding myself to Northern Virginia Community College – Alexandria Campus for use in educational/vocational planning.  All information will be kept confidential and maintained as part of my records with the Disability Services Office.  I authorize the release of information to include one or more of the following records:

 

q  Prescribed Medications/Dosages which might affect learning _____

q  Share verifications documentation with other NVCC Colleges, Continuing Ed Sites and ELI _____

q  Share verification documentation with The Career Place (Service Source and NVCC) _____

q  Learning Disability Assessment Results _____

q  Psychological Evaluation Results _____

q  Vocational Rehabilitation Plan _____

q  Audiology and Speech/Language Pathology Reports _____

q  Other _____

 

I further give permission for the Disability Services counselor(s) to discuss my educational situation with other professionals who have a legitimate educational need to know.  This authorization shall remain in effect until revoked in writing by the student or by ____________________________, whichever comes first (not to exceed two years from the date signed).

 

 

________________________________________                   _____________________________

                Signature of Student                                                                                           Date

 

________________________________________                   _____________________________

                Signature of Parent/Guardian                                                                           Date

                (Required for Student under 18 years of age)

 




A PHOTOCOPY IS AS VALID AS THE ORIGINAL

 

Please return information to:            Carol Sweetser

                                                                NOVA College Administration

                                                                4001 Wakefield Chapel Rd.

                                                                Annandale, VA 22003-3796

                                                                703-323-3187      Fax 703-323-4228