Disabled Students Programs & Services
PRIVATE INFORMATION CONSENT FORM
Notice: A photocopy of this signed form is as valid as the original.
Student’s Last Name
I provided the Disabled Students Program & Services (DSPS) with copies of school and/or
medical records containing information regarding my disability in order to receive disability
support services at Mt. San Jacinto College.
I hereby authorize DSPS to discuss my educational situation with the following personal individual(s):
Name: ____________________________________ Relationship: _______________________________________
By signing this document, I understand my rights to privacy, and herby authorize the Mt. San Jacinto
College District - Disabled Students Program & Services to discuss my private information with any
approved personnel so long as a legitimate need exisits.
Student Signature: ___________________________________
Signature of Parent or Guardian: __________________________ Date: __________________
(Required for Students Under 18 Years of Age)
DSPS Staff Signature: __________________________________
*The Mt. San Jacinto Community College District uses the information requested in this packet for the purpose of determining a student’s eligibility to
receive authorized special services provided by the Disabled Students Programs and Services (DSP&S) Program. Personal information provided to the
DSP&S program will be kept confidential in order 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 statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232 (g)). The
information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of
Regulations, Title 5, Section 56000 et seq.
I give permission for DSPS staff members to discuss my educational progress or the lack
of with other professionals who may have a legitimate educational need to know. This
shall remain in effect during my enrollment at MSJC or until revoked in writing.