Release of Information Form for Residential Life

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 Residential Life 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.

 __   __  _____  _       _  __         _ 
 \ \ / / |__  / | |__   | |/ / __  __ (_)
  \ V /    / /  | '_ \  | ' /  \ \/ / | |
   | |    / /_  | | | | | . \   >  <  | |
   |_|   /____| |_| |_| |_|\_\ /_/\_\ |_|

Enter the code above *

Enter the code depicted in ASCII art style.