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
I,
the undersigned, consent to and request all appropriate persons and/or agencies
or institutions to release information regarding myself to
q
Prescribed
Medications/Dosages which might affect learning _____
q
Share
verifications documentation with other
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