Columbia College
Disabled Students Programs and Services
11600 Columbia College Drive Sonora, California 95370
Phone: 209-588-5130 Fax: 209-588-5058
Disabled Student Programs & Services
Consent for Release of Information
Today's Date Student ID
Name: Last, First, M
Date of Birth
Maiden Name or Other
Release Statement:
I, the undersigned, authorize the release to Columbia College's Disabled Student Programs & Services (DSPS) of my
personal records by appropriate personnel, agencies, or institutions who may hold those records in assistive areas
listed below. I understand that release of informational items is contingent upon compliance with the Family
Educational Rights and Privacy Act (FERPA) of 1974 or other pertinent laws, regulations, or policies. I also authorize
the DSPS staff to use the obtained information in order to assist me in my educational attainments, and related
educational/vocational planning. Additionally, I give permission for DSPS Certificated staff members to discuss my
educational progress or the lack of with other professionals who may have a legitimate educational need to know.
I authorize release of information in areas I have checked below:
Disability Verification
Psychological Testing and Evaluation of Results
Learning Disability Assessment
Audiology and Speech/Language Pathology Reports
Vocational Rehab Plan
Educational Records
Other
Student Signature Date
DateParent/Guardian Signature
Agency Name
Agency's Phone number
Agency's Fax number
Agency Address
City State Zip Code
(Only required if student is under 18 years of age)
Revised 06/29/16 KR/CH
I authorize DSPS to release my information to the following agency / doctor / person
I authorize DSPS to request my information from the following agency / doctor/ person
Please check the appropriate box:
AttentionDepartment
click to sign
signature
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click to sign
signature
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