T +61 7 5430 2890 E AccessAbility@usc.edu.au W www.usc.edu.au/AccessAbility-Services
AccessAbility Services - Authority to Release Form
To assist AccessAbility Services to provide students with the most appropriate support, it may be necessary to exchange
information with other individuals, including University staff members and external service providers.
I hereby give consent to, and permission for, a representative of AccessAbility Services to:
Obtain information from and/or release information to:
Name: ____________________________________________________________________________________
Relationship to me or Profession: ______________________________________________________________
Organisation (if applicable): ___________________________________________________________________
Email: ______________________________________________________________________________________
Phone: ______________________________
Please specify if there is any information that you DO NOT consent to have
Notwithstanding the above, in certain circumstances the University may also need to disclose your personal information (if
relevant to your participation in a placement) to placement organisations as required under a Student Placement
I have read and understood the above information. I understand how my information will be used and/or obtained,
and that this information will not be released to, or obtained from, any other third parties except as outlined above.
I also understand that I may revoke this consent at any time by advising AccessAbility Services in writing.
Student name and ID: __________________________________________________________
Sign: ________________________________________________________________________
Date: ________________________________________________________________________
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