CONSENT FOR RELEASE OF INFORMATION RIVERSIDE CITY COLLEGE
Name: _____________________________________________________________________________________________________
Last First M
Social Security #: ___________________________________ Date of Birth: ______________________________________
Maiden Name or Other Used: ___________________________________________________________________________________
Last First M
I, the undersigned, request any appropriate person and/or agency or institution to release information consistent with the Federal
Family Educational Rights and Privacy Act of 1974, or other laws, regulations, or policies to RIVERSIDE CITY COLLEGE for use
in educational/career planning. All information will be kept confidential and maintained as part of my records with the DSP&S Office
at the college. I authorize the release of information to include one or more of the following records:
Please INITIAL All That Apply:
____ Verification of disability/general medicine
____ Psychological testing and evaluation results
____ Audiology and speech/language pathology reports
____ Educational records, Individual Education Plan (IEP), including progress made
____ Vocational Rehabilitation Plan (IPE)
____ Detailed results of Learning and/or disabilities (psychological or medical testing
that led to the diagnosis)
Other: _____________________________________________________________________________________
I further give permission to DSP&S Counselors and/or staff to discuss and share information in these records with other professionals
in the Riverside Community College District who have a legitimate educational need to know.
This authorization shall remain in effect until revoked in writing by the undersigned.
Student Signature: _________________________________________________________________ Date: ____________________
Signature
Parent or Guardian Signature: ________________________________________________________ Date: ___________________
Required for students under 18 years of age
Riverside City College • 4800 Magnolia Avenue Riverside, California 92506-1299
(951) 222-8060 • TDD (951) 222-8061• FAX (951) 222-8059
The Riverside Community College District uses the information requested on this form 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 recorded on this form 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)). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. § 552a, note), providing your
social security number is voluntary. 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.
A PHOTOCOPY OF THIS IS AS VALID AS THE ORIGINAL
