CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Disability Support Services (DSS)
Name of Agency/School
Date of Birth
You are hereby authorized to release pertinent medical, psychological, social or educational
information that the following agency and/or person may request about me. Send information
Disability Support Services
Big Bend Community College
7662 Chanute Street NE.
Moses Lake, WA 98837
This information will be used only as an aid in providing educational support services for which I
The requesting agency/person has the responsibility of keeping this information confidential and
will not release this information to any other agency or person without my written consent.
Student Signature Date
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