CRAFTON HILLS COLLEGE DISABLED STUDENTS PROGRAMS & SERVICES (DSPS)
CONSENT FOR RELEASE OF INFORMATION
Please print or type with blue or black ink
Student’s
Name:__________________________________________________Date of Birth:_______________________
Last First Middle Initial M/D/Y
SS# or ID:
Maiden Name or Other Name Used:
Last First Middle Initial
I, the undersigned, request any appropriate person and/or agency or institution to release information
consistent with the Federal Family Educational Rights and Privacy Act of 1974, or other laws, regulations, or
policies to this college for use in educational/vocational planning. All information will be kept confidential and
maintained as a part of my records with the Disabled Student Program and Services office at Crafton Hills
College. Selected information may be released for mandated State and/or Federal reports. I authorize the
release of information, which may include one or more of the following records:
Verification of disability
Psychological testing and evaluation results
Learning disability assessment
Audiology and speech/language pathology reports
Vocational rehabilitation plan
Prescribed medications and dosage
Educational records including progress made
Other:
I further give permission for DSPS certificate program staff to discuss my educational situation with other
professionals who have a legitimate educational need to know.
This authorization shall remain in effect during my enrollment at Crafton Hills College or until revoked in
writing.
Student's Signature: Date:
Parent or Guardian's Signature: Date:
Required for student under 18 years of age
A photocopy of this is as valid as the original.
