Fillable Olr-release OFFICE OF DISABILITY SERVICES

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Olr-release OFFICE OF DISABILITY SERVICES

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NOTE: Complete and submit this form (a) by sending as a pdf file from the student’s UD email
address to disabilityservices@udayton.edu; (b) by delivering a print copy to the Office of Learning
Resources, Roesch Library Room 023.
Jan 2019
Office of Learning Resources
AUTHORIZATION TO RELEASE INFORMATION
Last Name
First Name
M.I.
Student ID Number
The Office of Learning Resources makes every effort to protect the confidentiality of information
related to its services. All information maintained in OLR including use of service,
correspondence, consultation data, documentation, and accommodation letters are considered
confidential and will be managed in accordance with the Family Educational Rights and Privacy
Act of 1974 (FERPA).
By signing this document, I give my consent to the Office of Learning Resources to release
and/or discuss information from my file with the following parties, as designated below:
Name and Relationship to student (e.g. parent, spouse, sibling, friend, instructor / professor,
other university personnel)
Name and Relationship to student
Name and Relationship to student
Name and Relationship to student
Types of Information
Dis
ability Services information
Voluntary Medical Withdrawal information
This authorization can be revoked by me at any time with written notification to the
Office of Learning Resources.
Student Signature
Date
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Olr-release OFFICE OF DISABILITY SERVICES

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Completed 14 March 2020

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