Fillable Los Angeles Valley College Authorization for release of (Los Angeles Valley College)

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Los Angeles Valley College Authorization for release of (Los Angeles Valley College)

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Los Angeles Valley College
Services for Students with Disabilities
5800 Fulton Avenue• Valley Glen• CA• 91401
Phone:(818)
947-2681 • Fax: (818) 778-5775
E-mail: ssd@lavc.edu
Must attach a photo ID to your request
Authorization for release of information
I hereby authorize Los Angeles Valley College, Services for Students with Disabilities, to
release information concerning my disability.
Information Requested/ Special Instructions: (please specify)
Please mail /fax/ email my information to:
My phone/contact number is:
Student's Name:
Student's Signature:
Date:
Signature of Parent/Guardian: (If student is under 18 years of age)
Student ID: Date of Birth:
FOR
OFFICE USE ONLY
SSD copies: Mailed/ Faxed/ Emailed
Initial Date:
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Los Angeles Valley College Authorization for release of (Los Angeles Valley College)

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Completed 29 September 2020

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