Student Disability Services/ADA
P.O. Box 2216 / Decatur, AL 35609
Phone: (256) 306-2630 / Fax: (256) 260-2447
REQUEST TO RELEASE INFORMATION
I, _____________________________________________________ (______________________________),
FULL NAME (FIRST, MIDDLE, LAST) ID NUMBER
hereby give authorization to Student Disability Services/ADA of Calhoun Community College
to release a statement of the academic adjustments and modifications I receive/received at Calhoun
Community College to:
__________________________________________________________________________________
NAME OF PERSON, AGENCY, SCHOOL, ETC.
__________________________________________________________________________________
ADDRESS
_________________________________________________________________________________
PHONE NUMBER/FAX NUMBER (IF KNOWN)
I further understand that by signing this written request, Calhoun Community College cannot be held liable for
the exchange or release of such information.
Signature: ________________________________________________
Date: ____________________________________________________
FOR SDS/ADA OFFICE USE ONLY
Date received: ___________ by: _________
Date sent: _______________ by: _________
