WOODLAND COMMUNITY COLLEGE
Department of Supportive Programs and Services (DSPS)
2300 East Gibson Road, Building 700, Room 764, Woodland, CA 95776
Phone: (530) 661-5797 Fax: (530) 661-5788 Email: wccdsps@yccd.edu
Consent for Disclosure to Parents
_______________________ _______________________ _______________________
Student Last Name First Student ID
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Street Address City State ZIP
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Phone Email DOB (MM/DD/YY)
I consent to the disclosure of information from my educational records to my parent/guardian
for reasons determined as appropriate by the DSPS of WCC.
__________________________________________ _____________
Student Signature Date
Parent/Guardian 1
_______________________ _______________________ _______________________
Last Name First Phone Number
_______________________ _______________________ _______ _____________
Street Address City State ZIP
Parent/Guardian 2
_______________________ _______________________ _______________________
Last Name First Phone Number
_______________________ _______________________ _______ _____________
Street Address City State ZIP
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