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:
This information is for professional purposes only and is confidential in nature.
_____ _ __ __ ____ | ___| _ __ ___ __| | \ \ / / _ _ | ___| | |_ | '_ ` _ \ / _` | \ V / | | | | |___ \ | _| | | | | | | | (_| | | | | |_| | ___) | |_| |_| |_| |_| \__,_| |_| \__,_| |____/