620.343.4600 | 800.711.6947 | fax: 620.343.4610 www.fhtc.edu 3301 West 18th avenue | emporia, Kansas 66801
RElEASE OF INFORMATION | FORM THREE
CONFIDENTIAl DOCUMENT
To: Vice President of Student Services
Flint Hills Technical College
I hereby give the Dean of Students Services at Flint Hills Technical College, permission to share information with the following persons/agencies:
ALL AGENCIES AND/OR PERSONS WITH A LEGITIMATE EDUCATIONAL NEED TO KNOW.
(Or, check specic groups below with whom we may share information.)
All Faculty,
Specic Faculty Only (please list):
Academic Advisors
Other College Personnel
Previous Educational Institutions
Medical/Counseling Facilities
Recordings for the Blind
Department of Rehabilitation
Other (please list):
I understand that I must provide medical or other diagnostic documentation of my disability and limitations, prepared by a qualied physician,
psychologist, or professional which states the parameters of my disability, to the Vice President of Student Services.
Name: Social Security Number:
Student Signature: Date:
This condential form will be in effect from the date signed and shall remain effective during my admission to Flint Hills Technical College unless
superseded by the signing of a new form.
Rev. 11/25/2013
Last First
mm/dd/yyyy
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
