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Form
125-138 Rev.
10/28/08 |
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Disability
Support Services: Consent for Release
of Information Name:
_____________________________________________________________________________________ Last First Middle NOVA Student #: ____________________________________ Date of Birth: _________________________
__ MM/DD/YY Maiden name or other used:
___________________________________________________________________ Last First Middle Campus of Record: AL _____ AN _____ LO _____ MA _____ WO _____ MEC _____ ELI _____ 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
for use in educational/vocational planning.
All information will be kept confidential and maintained as part of my
records with the Disability Support Services Office. I authorize the release of information to
include one or more of the following medical records: q Medical
Reports q Learning
Disability Assessment Reports q Psychiatric
Evaluation Results q Vocational
Rehabilitation Plan q Audiology
and Speech/Language Pathology Reports q Other
______________________________________________________________________________________ I further give permission
for the Disability Support 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: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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