Academic Resource Center
470 E. Lockwood Ave., Saint Louis, MO 63119-3141 USA
Phone: 314-246
-7620 Fax: 314-968-5919
www.webster.edu/arc
Home Campus: St. Louis, MO, USA
Release of Information
(Name) (WebsterID) (Phonenumber)
IherebyauthorizeWebsterUniversitytonotifythefollowingindividualsofmydisabilityordisabilities
andtodiscussmyaccommodations andacademicneedswiththem.Bydoingso,IamensuringthatI
haveaccesstoinformationandtheopportunitytoachieveacademicsuccessequivalenttothatprovided
tostudentswithoutdisabilities.
Informationtobesenttoinstructors:

Webster Universitymay(pleaseinitial):
Printandsendlettersofaccommodationandtheaboveselectedhandoutstomyinstructors.
SendmyclassscheduletothePublicSafetyofficefor
useintheeventofanemergency.
CollaboratewithWebst
erfacultyandstaffasappropriate.
Exceptions:
Collaboratewithphysicians,therapists,VocationalRehabilitat
ion,orRehabilitation
ServicesfortheBlindasappropriate.Exceptions:
Collaboratewithfamilymembersorothers(pleaseli
stnamesandphonenumbers).
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
IunderstandthatonlythoseindividualsorgroupswhoseitemsIhaveindicatedabovehavemy
permissionforthereleaseofinformationconcerningmydisabilityordisabilities.Ascircumstances
change,Imayupdatethisreleaseofinformation.
(Studentsignature) (Date)
AutismSpectrumhandout
CARTserviceshandout
Signlanguageinterpreterhandout
Seizurehandout
Serviceanimalhandout
Other:
(Home campus only.)
click to sign
signature
click to edit
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