PERMISSION TO DISCLOSE RECORDS
I, , hereby authorize the release and disclosure of my
records for use of providing educational accommodations while enrolled at VGCC. These documents will
be held in the Office of Accessibility with the Accessibility Coordinator. VGCC is issuing the following
document collection in order to accommodate students under the Americans with Disability Act (ADA)
and Section 504 of the Rehabilitation Act. The documents requested are to provide/include the diagnosis
that is covered under the aforementioned laws. I understand I am expected to satisfy the academic
standards required by the college and be able to perform the essential course functions without
substantially altering the curriculum. Documentation may cover one or more of the following areas:
□ Autism
□ ADD/ADHD
□ Substance abuse
□ Mental health
□ Learning disability
□ Blind/Visual impairment
□ Deaf and hard of hearing
□ Medical/ Physical condition permanent or
temporary
□ Other, Please list
____________________________________________
Agency/Provider: Contact Person:
Address: City/State/Zip:_
Phone: Fax:
This authorization allows the above individual and/or organization to copy and send records to the
authorized VGCC representative to review the records and discuss my condition with said individual and/or
organization to determine reasonable accommodations. This authorization encompasses records pertaining
to my condition, including “third party records” created by any other individual or organization. I have the
right to revoke this authorization in writing at any time, except to the extent that action has already been
taken to comply with it.
Send documents Attention: Office of Accessibility Fax number: 252 738 3256
VGCC P.O. BOX 917 HENDERSON, NC 27536
Date:
Student Signature
Date of Birth
Date:
Parent/Guardian Signature (If Student is Under Age 18) Revised 5/2020
