Fillable Authorization to Release Confidential Records (Northwest Vista College)

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Authorization to Release Confidential Records (Northwest Vista College)

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DS FORM 2, FEB 2017 Page 1 of 2
Alamo Colleges, Student Success V1.01
AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION
1. STUDENT BANNER ID
2. LAST FOUR OF SOCIAL SECURITY
3. DATE OF BIRTH
4. STUDENT NAME (FIRST, LAST)
5. PRIMARY PHONE
6. ALTERNATE PHONE
REQUEST/RELEASE INFORMATION FROM
7. NAME OF ORGANIZATION
8. CONTACT PERSON
9. E-MAIL
10. ADDRESS
11. PRIMARY PHONE
12. ALTERNATE PHONE
13. FAX
REQUEST/RELEASE INFORMATION TO
14. NAME OF ORGANIZATION
15. CONTACT PERSON
16. E-MAIL
17. ADDRESS
18. PRIMARY PHONE
19. ALTERNATE PHONE
20. FAX
21. INFORMATION REQUESTED: (CHECK ALL THAT APPLY) CHECK ALL THAT APPLY:
☐Documentation/Statement of Disability
☐Medical Records
☐Psychological Evaluation
☐History of Disability
☐Psycho-Educational Assessment
☐Academic and/or intellectual Assessments
☐Comprehensive Individual Assessment
☐Full Individual Evaluation (FIE)
☐Current or Previous Accommodations
☐Other: All educational access
☐Information relating to an emergency situation in which I am involved while on campus
PRINCIPAL PURPOSE: Request by St. Philip's College for the release of confidential records from
external sources for a student in an academic setting.
ROUTINE USES:
Used to evaluate and determine accommodations for students.
Authorization to Release Confidential Records
The proponent department is Disability Support Services
THIS FORM IS PROTECTED UNDER THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974
Authorization to Release Confidential Records
The proponent department is Disability Support Services
DS FORM 2, FEB 2017 Page 2 of 2
Alamo Colleges, Student Success V1.01
I authorize St. Philip's College to request/release the above information. I understand that my records will
be kept confidential and are protected by Federal Regulation/State Law. I also understand that I may
revoke this consent at any time, and that my records will not be released without my signed consent.
23. DATE
25. DATE
The Alamo Colleges District will not discriminate against any employee, applicant for
employment, student or applicant for admission on the basis of race, color, sex, pregnancy,
religion, creed, national origin (including ancestry), citizenship status, physical or mental
disability, age, marital status, sexual orientation, gender, transgender status, gender
identity, gender expression, veteran or military status (including special disabled veteran,
Vietnam-era veteran, or recently separated veteran), predisposing genetic characteristics,
domestic violence victim status, any other protected category under applicable local, state
or federal law, or persons who have opposed discrimination or participated in any
complaint process on campus or before a government agency.. Inquiries or complaints
concerning these matters should be brought to the attention of: Linda Boyer-Owens,
Associate Vice Chancellor of Human Resources and Organizational Development, Title IX/
VII/ADA/504 Coordinator, (210) 485-0200. Address: Human Resources Department, 201 W.
Sheridan, Bldg. A, San Antonio, Texas 78204.
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Authorization to Release Confidential Records (Northwest Vista College)

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Completed 7 October 2020

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