AUTHORIZATION FOR RElEASE OF INFORMATION BY lICENSED PHYSICIAN OR PROFESSIONAl
To :
Day Time Phone: Evening Time Phone:
I, the undersigned student, am requesting special services from Flint Hills Technical College and hereby request and authorize you to release any
information pertaining to my disability.
Student’s Full Name:
Date of Birth: Social Security Number - -
Signature of Student: Date:
Last First Middle JR., etc.
Doctor ect.
Street Address
City State Zip
DISABIlITY VERIFICATION
In order to provide the student with special educational services designed to help him/her be more successful in college, we require a
verication of the students disability. Please provide the following information:
Diagnosis
Limitations Functional limitation(s) resulting from the condition/disorder that would, in your opinion impede the student’s
educational performance. Please check all that apply:
Poor concentration, distractibility and/or confusion.
Intense anxiety, phobia, and/or panic.
Difculty completing assignments due to pressures.
Difculty in taking notes, reading college texts, taking tests and/or managing time.
Problems in hearing and/or speaking in class discussions.
Other
Signature of Professional
Title Date
After a qualied professional has completed the disability verication section, please mail to: Flint Hills Technical College, Attn: Vice President of
Student Services, 3301 West 18
Th
Avenue, Emporia KS 66801. Or email the completed pdf to lkirmer@fhtc.edu.
mm/dd/yyyy
mm/dd/yyyy
620.343.4600 | 800.711.6947 | fax: 620.343.4610 www.fhtc.edu 3301 West 18th avenue | emporia, Kansas 66801
DISABIlITY FORM A
Rev. 11/25/2013
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
