Last First
I hereby consent to the release of information from my student records maintained by _____________________
___________________________________consistent with the Federal Family Education Rights and Privacy Act
of 1974, or other laws, regulations, or policies; to designated representative of other educational institutions in
order that they may determine my eligibility for and need of special services provided by their institutions.
_____ Learning disability assessment
_____ Verification of disability
_____ Psychological testing and evaluation results
_____ Audiology and speech/language pathology reports
_____ Vocational rehabilitation plan
_____ Prescribed medications and dosage
_____ Educational records, including progress made
I further give permission for the DSP&S certificated professional(s) to discuss my educational situation with
other professionsl who have a legitiate educational need to know, such as instructors who need to know about
test proctoring, etc. This authorization shall remain in effect during my enrollment or until revoked in writing by
the undersigned.
Signature of Student Date
Signature of Parent or Guardian Date
