Fillable RELEASE OF INFORMATION (Laramie County Community College)

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RELEASE OF INFORMATION (Laramie County Community College)

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LARAMIE COUNTY COMMUNITY COLLEGE
RELEASE OF INFORMATION
_________________________________________________________ Student ID Number ________________
               (print full legal name)
I hereby authorize Laramie County Community College to release all informaon for the 20___-20___ and 20___-20___ academic
year(s) regarding
Disability Support Services.
Name ____________________________________________________ Relaonship _______________________________________
Name ____________________________________________________ Relaonship _______________________________________
For account security, you must also specify an account authorizaon password. The above listed individual(s) must know this
password as well as your name and ID number in order for LCCC to release any informaon to them. The password should be one
word; the word “password” is not acceptable.
Password: ________________________
I authorize the release of this informaon for the purpose of Disability Support Services at Laramie County Community College.
I understand that this release of informaon may be revoked at any me by contacng the LCCC Disability Support Services and that
this release covers only the terms indicated and must be re-submied if LCCC is to disclose informaon past the me frame indicated
on this form.
Signature _____________________________________________
Date _________________________________________________
Mail to: Laramie County Community College
Disability Support Services
1400 E. College Dr.
Cheyenne, WY 82007
PRS 5784 8/18
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RELEASE OF INFORMATION (Laramie County Community College)

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Completed 27 July 2020

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