Fillable CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION Disability Support (Big Bend Community College)

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION Disability Support (Big Bend Community College)

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Disability Support Services (DSS)
I, (Student Name) do hereby give permission to the
Coordinator of Disability Services at Big Bend Community College to provide and/or receive
pertinent medical, psychological, social, disability or educational information to/from the
following persons or agencies:
Please list by name:
This information may be used to assist in determining and implementing appropriate
accommodations, modifications, and/or services.
Student Signature Date
Revised 6/5/18
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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION Disability Support (Big Bend Community College)

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Completed 4 February 2021

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