Collection and use of Personal Information
The University of Victoria collects, uses, discloses and retains personal information only in compliance with the University Act and the
British Columbia Freedom of Information and Protection of Privacy Act. The University of Victoria collects the personal information on
this form pursuant to section 26(a) and (c) of the Freedom of Information and Protection of Privacy Act.
The information provided in this form will be used only for the purposes of recording consent for the release of information on
disability related academic accommodations. For a detailed listing of the types of personal information the University collects and the
purposes for such collection see Schedule A, Procedures for the Management of Personal Information. Should you have any questions
concerning your personal information, please contact the University Secretary’s office at foipp@uvic.ca or (250) 472-4914.
As a condition of registering with the Centre for Accessible Learning (CAL), you are required to give your consent to the exchange of
information about your required academic accommodations with your instructors and appropriate staff of the University of Victoria
(Section A). If you wish to give permission to CAL to release information to other individuals or institutions, please complete Section
B of this form as well.
This consent is considered valid for the duration of your study at the University of Victoria. You may withdraw or amend your
consent at any time by notifying CAL in writing. Please refer to the University’s Protection of Privacy policy (GV0235) for more
information on the University’s obligation to protect your personal information.
Name:_______________________________________________________________ Student Number: ________________________
Phone Number:___________________________________ Email:______________________________________________________
A. Consent for Release of Information
I hereby give the Centre for Accessible Learning (CAL) of the University of Victoria permission to release information on disability
related academic accommodations to appropriate instructors, academic and/or support staff and/or other student services at the
University of Victoria. I understand that the University will make reasonable security arrangements to protect my personal
information, and will only use and disclose my personal information in compliance with the University Protection of Privacy policy
(GV0235). By typing your name in the Signature field below, you have officially given consent to share this information, as listed
above.
Signature:__________________________________________________________ Date: ____________________________________
B. Consent to Exchange Information
I hereby give the Centre for Accessible Learning (CAL) of the University of Victoria permission to exchange information with (name,
contact info, relationship to you):
___________________________________________________________________________________________________________
on matters relating to my disability and the related need for academic accommodations. I understand that the University will make
reasonable security arrangements to protect my personal information and will only use and disclose my personal information in
compliance with the University Protection of Privacy policy (GV0235). By typing your name in the Signature field below, you have
officially given consent for the CAL to exchange this information with the person(s) listed in the above field.
Signature:__________________________________________________________ Date: ____________________________________
