DisAbility Services • 1401 E. Court St. • Flint, MI 48503 • Phone: (810) 232-9181 • Fax: (810) 232-9943
Revised: 5/20/2015 9:03AM
Disability Services
Authorization to Disclose Disability Information
I, the undersigned, authorize Mott Community College/Disability Services to release the
following information. This authorization will remain in effect until the student submits written
notice terminating this consent to the Office of Disability Services.
Documentation of disability
Information related to student’s Disability Services file
Other:
Student Information:
Name: Date of Birth:
Social Security #: XXX – XX -
Name of organization/individual to which disclosure is to be made:
Name:
Contact Phone Number:
Preferred Method of Release:
US Mail Address:
Fax Fax Number:
Email Email:
Student’s signature Date
* Students wanting to allow a designee to access your education record and conduct business on your behalf should
complete Mott Community College’s Authorization to Disclose Information form and submit it to the Registrar. The
form can be found at the Form Center: http://www.mcc.edu/mcc_form_center.shtml
Date Received: Received By:
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
