Fill - Free fillable Release of Information (Webster University) PDF form

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) (WebsterID) (Phonenumber)

IherebyauthorizeWebsterUniversitytonotifythefollowingindividualsofmydisabilityordisabilities

andtodiscussmyaccommodations andacademicneedswiththem.Bydoingso,IamensuringthatI

haveaccesstoinformationandtheopportunitytoachieveacademicsuccessequivalenttothatprovided

tostudentswithoutdisabilities.

Informationtobesenttoinstructors:





Webster Universitymay(pleaseinitial):

Printandsendlettersofaccommodationandtheaboveselectedhandoutstomyinstructors.

SendmyclassscheduletothePublicSafetyofficefor

useintheeventofanemergency.

CollaboratewithWebst

erfacultyandstaffasappropriate.

Exceptions:

Collaboratewithphysicians,therapists,VocationalRehabilitat

ion,orRehabilitation

ServicesfortheBlindasappropriate.Exceptions:

Collaboratewithfamilymembersorothers(pleaseli

stnamesandphonenumbers).

___________________________________ ___________________________________

___________________________________ ___________________________________

IunderstandthatonlythoseindividualsorgroupswhoseitemsIhaveindicatedabovehavemy

permissionforthereleaseofinformationconcerningmydisabilityordisabilities.Ascircumstances

change,Imayupdatethisreleaseofinformation.

(Studentsignature) (Date)

 AutismSpectrumhandout

 CARTserviceshandout

 Signlanguageinterpreterhandout

 Seizurehandout

 Serviceanimalhandout

 Other:

(Home campus only.)

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