Fillable Information Release Form Osa (Pepperdine University)

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Information Release Form Osa (Pepperdine University)

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(7/18/2017)
INFORMATION RELEASE FORM
Pepperdine University
Office of Student Accessibility
TCC 264 | 310.506.6500
Please Print or Type
STUDENT NAME
Last First M.I.
CAMPUS WIDE I.D. #
CAMPUS BOX # (or off campus local address where you receive mail)
CITY
STATE
ZIP CODE
PHONE #
EMAIL ADDRESS:
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE #
Release of Information
I hereby give permission to the staff of the Office of Student Accessibility to discuss my
accommodation needs with Pepperdine University faculty and/or staff who request such
information either verbally or electronically.
I also give permission for OSA staff to speak with the following individuals outside of
Pepperdine University (this could be a parent or other family member, physician,
psychologist, etc): Please use additional paper as necessary.
_______________ _________________ ______________ _______________
Name Relationship to student Phone Email
_______________ _________________ ______________ _______________
Name Relationship to student Phone Email
_______________________________ _______________
Student initials Date
Additional Notes/Comments: _____________________________________________
CONFIDENTIAL
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Completed 24 July 2020

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