05-21-2020
PERMISSION TO RELEASE & EXCHANGE INFORMATION
Disability Services Office
Student Name: ______________________________________________________________
Student ID #: __________________________ Date of Birth: _____________________
I am 18 years of age and my own legal guardian. ____Yes ____No
If No, legal guardian’s full name: _________________________________
I give Nashua Community College’s Disability Services Coordinator permission to discuss pertinent educational,
psychological, and/or medical records for the purpose of providing accessibility/disability support services at NCC.
This includes contact by e-mail, fax, telephone, and in person.
NCC may release/exchange information with the individuals listed below:
Name of Person Relationship or Agency Contact Information
1. ____________________________ ____________________________ ____________________________
2. ____________________________ ____________________________ ____________________________
3. ____________________________ ____________________________ ____________________________
4. ____________________________ ____________________________ ____________________________
5. ____________________________ ____________________________ ____________________________
Note: You can include parents, siblings, significant others, doctors, counselors, Voc Rehab counselors, etc.
OR
_____ I DO NOT give permission to exchange information with outside persons regarding disability services at
NCC.
I understand and agree that the information will be released effective until the NCC Disability Services Coordinator has
received written notice to revoke this form.
You can revise the Permission to Release and Exchange Information form at any time by submitting an updated, signed
form.
Student Signature: ___________________________________________ Date: _______________________
Guardian Signature: ___________________________________________ Date: _______________________
Terms are effective upon date received by NCC Disability Services Office.
A copy of the Permission to Release & Exchange Information shall have the same force as the original.
505 Amherst Street | Nashua, NH | 03063 | P. 603 578-8900
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