____ Law Enforcement
____ Other: _______
________________________________________
(Form must be printed, signed, and returned to the Coordinator, ODS
Unless I authorize a change in the future, this form will remain valid throughout my enrollment at
Sandhills Community College.
______________________________
______________________________
Signature of Student
Printed Name
_______________
Date
Office of Disability Services
Confidential Release of Information Form
Information you share with the Office of Disability Services (ODS) regarding the nature of your disability
is considered confidential. Such information will be maintained in this office in a manner consistent with
state and federal law.
There may be occasions, however, when in order to facilitate the provision of accommodations, SAS
staff must speak with individuals outside of the office about your particular needs. Alternatively, a
student may request that their medical documentation or accommodation information be provided to a
person they identify.
I, the undersigned, give the Office of Disability Services permission to release the following information:
RELEASE (check all that apply):
____ Medication
____ Psychological
Evaluation
____ Test Results
____ Any information regarding my symptoms, limitations, accommodations and academic support needs
____ Only the following
information pertaining to my case: __________________________
____ Tutoring/Testing Center ____ First Responders
RELEASE TO (check all that apply):
____ Instructors
____ Counselors
Student ID# _________
115 Logan Hall
(910) 246-4138
(
910) 246-5370, Fax
