Disability Services Office
Laboratory Building
Telephone: (707) 654-1283
disabilityservices@csum.edu
Information Release Authorization
I, ___________________________________________, ________________________________
Student’s Name Student’s ID #
authorize _____________________________________________________________________
Name of hospital, clinic, school or agency
or its director, designee or records department to release the informaon contained in my
records to the individual or organizaon listed below:
Vineeta Dhillon, Director
Disability Services Oce, Cal Marime
200 Marime Academy Drive
Vallejo, CA 94590
Telephone: 707-654-1283
Fax: 707-654-1159
E-mail: vdhillon@csum.edu
Specic type of informaon disclosed:
Psychological, vocaonal interest and aptude test
Medical records of treatment for physical and/or emoonal illness
including treatment records for substance abuse
For the purpose of:
Establishing eligibility for academic accommodaons
Other (please specify): _______________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________ _______________________
Signature Date
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signature
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