Office Use Only: Date Received _________________
Student Consent to Release
Documentation from DSS File
I, _____________________________________________ , hereby request and authorize Southwestern
College Disability Support Services to release specific information (indicated below) from my record which bears
on my medical/health condition and/or educational development to the following party or to my SWC student
email address:
Name of Person/Organization _________________________________________________________________
Address ___________________________________________________________________________________
City ________________________________________________________State _______Zip _______________
Phone ____________________________________Fax ____________________________________________
Email _____________________________________________________________________________________
Release to self, the below listed student
Specific documents authorized for release:
DSS Documentation
SWC Learning Disability Assessment
Academic Accommodation Letter
Academic Accommodation Plan
Student Educational Contract
Other
Third-Party Documentation
(Released to student only)
Vocational Rehabilitation Plan
Audiology or speech/lang. report
K-12 Educational records (ie. IEP, 504)
Psychological Testing/Eval Results
Verification of disability
Medical verification
VA Reports/Records
Other Institutional LD Assessment
Per FERPA (Family Educational Rights and Privacy Act of 1974) regulations the institution has a period of up to 45 days to
produce copies of a student educational record. DSS, with good faith effort, will have copies of specific records ready for
mailing, student pickup, email or fax within five working days from the received date on this request. Requests received
by email, mail or fax MUST include a copy of your valid photo ID (driver's license, state ID, school ID).
I authorize release of the information indicated above from my student file.
Student Signature _________________________________________ Date: ____________________________
Printed Name: ____________________________________________ SWC ID #: ________________________
SWC Student Email Address ___________________________________________________________________
