Disability and Access Services: Release of Information

Release of student information consists of the following:

• Student name
• Student ID number
• Date of birth

I hereby authorize Lower Columbia College, DAS Director, Mary Kate Morgan, to provide information contained in the educational records of the above named person to the following named individuals or organizations:

All agencies and/or persons with legitimate educational need to know:

Or check specific groups below with whom we may share information.

• All faculty
• Specific faculty only (please list)
• Parents or guardians (names)
  • Previous/future educational institutions
  • Medical/counseling facilities
  • Recordings for the Blind/Library for the Blind
  • Department of Vocational Rehabilitation
• Department of Labor & Industries (L&I)
• Other (please identify)

This release is in effect for the period of:

I understand that I must have documentation on file at the DAS Office to be eligible for services as a student with a disability. I have a responsibility to identify myself as a person with a disability on the registration form, and in the case of Federal auditors, my records may be opened.

• Signature of student
• Phone number/email
• Date