DisAbility Services • 1401 E. Court St. • Flint, MI 48503 • Phone: (810) 232-9181 • Fax: (810) 232-9943
Revised: 5/20/2015 9:12AM
Disability Services
Release of Information Authorization
I, the undersigned, authorize or its
director, designee, or records department to release information contained in my records to the
individual or organization listed below. This authorization will remain in effect until the student
submits written notice terminating this consent to the Office of Disability Services.
Student Information
Name: Date of Birth:
Social Security #: XXX – XX -
Name of organization to which disclosure is to be made:
Mott Community College
Disability Services – PCC 2280
1401 E. Court St, Flint, MI 48503
Phone: (810) 232-9181
Fax: (810) 232-9943
Information to be disclosed:
Purpose and need for such disclosure is to establish eligibility for support services to
accommodate a disability and/or determine type of service(s) or accommodation(s) needed.
This information is required in order for the individual to receive academic accommodation(s).
It is maintained in the office of The Learning Center and is kept confidential. This information
does not become part of the student’s permanent college record and is destroyed after a limited
time. Mott Community College cannot be responsible for any incurred fees.
Student’s signature Date
Date Received: Received By:
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