Durham Technical Community College
1637 Lawson Street / Durham, North Carolina 27703
919-536-7200 durhamtech.edu
1/2016
Consent to Release Disability Information
Please check the appropriate term and enter the year:
Fall Spring Summer
***Note: Students need to renew their accommodation request every year.***
I, , give permission to Durham Technical Community
College Disability Services Office permission to discuss the specifics of my disability, classroom
accommodations, and other disability related issues with the following:
Please indicate the individuals/groups with whom disability services staff are allowed to talk about
the specifics or nature of your disability by checking the appropriate boxes below.
Faculty members of the courses in which I am enrolled in a particular semester (please list below):
Outside agencies (e.g., DSS, Vocational Rehabilitation Services):
Academic advisors, counselors, financial aid advisors, and department heads
Administrators within the college who have a legitimate interest in appropriate accommodations
related to my disability
My parents, guardians, or spouse (please list below):
I understand and agree to the statements listed above. I understand that I can amend or cancel this
agreement through a written notice to the Disability Services Office.
Student signature Date
(If the student is less than 18 years of age, a parent or guardian must be present and understand the
statements within this agreement.)
Parent signature (if applicable) Date
FOR STAFF USE ONLY
I have reviewed this document with the student and have answered any questions that they
may have concerning Disability Services at Durham Technical Community College.
Staff signature Date
