Documentation Release Authorization
Name: _______________________________________________________________________
Former Name: ________________________________________________________________
Indicate any former name(s) under which records are listed
Home Address: ________________________________________________________________
Home/Cell Phone: _____________________________________________________________
Date of birth: ____/____/________
Name and address of the office from which documentation/information is requested:
______________________________________________________________________________
Name City State Zip
I, ____________________________________________, authorize the above institution to release
documentation regarding my disability to the Ancilla College Student Success Centers Services
for Students with Disabilities. I understand that this documentation must be received by
Ancilla College before services can be rendered and accommodations made.
______________________________________________________________________________
Student Signature Date
