Release of Information Form for Academics

University of Louisiana at Monroe
Self-Development,Counseling and Special Accommodations Center

PERMISSION TO RELEASE INFORMATION

I give my permission to the Self-Development,Counseling and Special Accommodations Center to release special need information to my instructors for the:

Semester *

Year *

This information is for professional purposes only and is confidential in nature.

Name: *

Date: *

Month

Day

Year

Phone: *

CWID: *

Date of Birth: *

Month

Day

Year

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

  ____    _   _    ____    ___    _____   ____  
 |___ \  | | | |  / ___|  / _ \  |___ /  | __ ) 
   __) | | | | | | |  _  | | | |   |_ \  |  _ \ 
  / __/  | |_| | | |_| | | |_| |  ___) | | |_) |
 |_____|  \___/   \____|  \__\_\ |____/  |____/

Enter the code above *

Enter the code depicted in ASCII art style.