Fillable CONSENT FOR RELEASE OF INFORMATION TO MIRAMAR COLLEGE (San Diego Miramar College)

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CONSENT FOR RELEASE OF INFORMATION TO MIRAMAR COLLEGE (San Diego Miramar College)

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File type: PDF

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SAN DIEGO COMMUNITY COLLEGE DISTRICT
Disability Support Programs and Services
CONSENT FOR RELEASE OF INFORMATION
TO MIRAMAR COLLEGE
C:\Users\rnipp\Desktop\Consent for Release - Incoming from School or College.doc
Student Information: Releasing Party:
Name
Educational Institution
Last First Middle
Address
K-12 ID#:
SSN#(Last 4 digits) Birth Date
Maiden/other name
Phone __________________ FAX _____________________
Last First Middle
I, the undersigned, consent to and request all appropriate persons and/or agencies/institutions to release information
regarding myself to San Diego Miramar College for use in educational/vocational planning. All information will be
kept confidential and maintained as a part of my records with the Disability Support Programs and Services office. I
authorize the release of information to include one or more of the following records:
K-12 School Psychologist’s Report and Academic Assessment Results
Audiology and Speech/Language Pathology Reports
IEP or 504 Report
Postsecondary Learning Disability Assessment Results
This authorization shall remain in effect until revoked in writing by the student.
Signature of Student Date
Signature of Parent/Guardian Date
(Required for Student under 18 years of age; requesting from a K-12 institution)
A PHOTOCOPY IS AS VALID AS THE ORIGINAL
Please return information to: San Diego Miramar College
Disability Support Programs and Services
miradsps@sdccd.edu
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CONSENT FOR RELEASE OF INFORMATION TO MIRAMAR COLLEGE (San Diego Miramar College)

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Completed 25 July 2020

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