Copper Mountain College
ACCESS
6162 Rotary Way, Joshua Tree CA 92252
(760) 366-3791 x5861
Confidential
CONSENT TO RELEASE OF INFORMATION
Nam
e: ________________________________________________________________________________
Last First MI
Date of Birth: ______________ Maiden name / other name used: _________________________________
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
Copper Mountain College (CMC) for use in educational /career planning. All information will be kept confidential
and maintained as part of my records with the ACCESS Office at CMC. I authorize the release of information to
include one or more of the following records:
P
LEASE CHECK ALL THAT APPLY:
_______ Verification of an individual’s disability signed by an appropriate medical practitioner,
osteopathic medical doctor, psychiatrist, psychologist, School psychologist, or
representative.
_______ Psychological testing and evaluation results
__
_____ Audiology and speech/language pathology reports
__
_____ Vocational Rehabilitation Plan
__
_____ Educational records, Individual Education Plan (IEP) including progress made
_______ Other
: _______________________________________________________
I further give permission to ACCESS staff to discuss these records with other professionals at Copper Mountain
College and the Department of Rehabilitation who have a legitimate educational need to know, and I give
permission for ACCESS to forward these records to other educational institutions upon my written request.
T
his authorization shall remain in effect until revoked in writing by the undersigned.
Student: _____________________________________________ Date: _____________________
Signature
P
arent or Guardian: ____________________________________ Date: _____________________
Signature required for student is under 18 years of age
A
PHOTOCOPY OF THIS RELEASE IS VALID AS THE ORIGINAL
CMC uses the information requested on this form for the purpose of determining a student’s eligibility to receive special services provided by
ACCESS. Personal information recorded on this form will be kept confidential in to protect against unauthorized disclosure. Portions of this
information may be shared with the Chancellor’s Office of the California Community Colleges or other state or federal agencies; however,
disclosure to these parties is made in strict accordance with applicable statues regarding confidentiality, including the Family Educational
Rights and Privacy Ace (20 U.S.C. 1232 (g). updated 3/09
C
opper Mountain Community College complies with all state & Federal regulations and does not discriminate on the basis of race, color
national origin, gender or disability. This holds true for all district employment and opportunities. Harassment of any employee or student
with regard to race, color, national origin, gender, or disability is strictly forbidden. Inquiries regarding compliance and/or grievance
procedures may be directed to the school district’s Title IX Officer and/or Section 504/ADA Coordinator. For the Title IX Officer and/or
504/ADA Coordinator contact the Human Resource Office, 6162 Rotary Way, Joshua Tree, CA 92252 (760) 366-5267
