Disability Support Services
900 Otay Lakes Road
Chula Vista, CA 91910
Phone (619) 482-6512
Fax (619) 482-6511
VP (619) 207-4480
High School Consent to Release Transcripts
And
Confidential Information
Student Name:
Student Address:
Student Birthdate:
I hereby authorize the agency listed below to release any confidential disability
information from their records that may include medical or health conditions
and/or educational assessments (including psychological evaluation data), etc. to
Disability Support Services at Southwestern College.
Name of school School City & State
Graduation Date/Last Date Attended
Information Requested:
High School Transcripts
Summary of Performance
Psychological Report
Most recent IEP
Speech/Language Report
504 Plan
Other:
Student’s Signature Date
To request this document in an alternative format, call (619) 482-6512, or VP (619) 207-4480.
Student Phone #:
Once your application and verification have been processed, please know that it can take up
to two weeks for you to be scheduled for an eligibility appointment.
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