Rev. 9/28/17 Page 1 of 1
Disability Accommodations & Support Services
One University Drive
Camarillo, CA 93012
Bell Tower 1541
Phone: 805-437-3331
Fax: 805-437-8529
REQUEST FOR RELEASE OF CONFIDENTIAL RECORDS FROM
DISABILITY ACCOMMODATIONS & SUPPORT SERVICES
Date of Request: Student Name:
Student ID Number: Student Phone Number:
I, , am requesting release of confidential records from California
State University Channel Islands Disability Accommodations & Support Services. I understand that DASS and
related organizations are required by law to keep my disability information confidential. I acknowledge that
release and authorization for disclosure of my protected disability information to someone who is not legally
required to keep information confidential as well as information in transit, means that my information may no
longer be protected by state or federal confidentiality laws. I am aware that DASS will not release my requested
records to any third party sources, and instead will only release the records directly to me. I am also aware that
this request may take up to 10 business days for processing.
I am requesting the following (please choose one):
Information requested for standardized testing (i.e., GRE, LSAT, GMAT, etc…).
Students must also include the form to be completed with this request.
Summary of my approved disability accommodations at CI
Verification letter confirming my registration with DASS
Copy of my documentation
Other
Preferred delivery method of disability file:
I will pick up file at DASS Send file electronically________________________________
Email Address
By signing below, I acknowledge that I have read and understand the information above and implications
regarding confidentiality.
Signature of student OR legal guardian/authorized person Date
