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:

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

CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
                  _   _       _   ____  
_ __ __ _ (_) | |__ | | | _ \
| '_ \ / _` | | | | '_ \ | | | |_) |
| |_) | | (_| | | | | | | | | | | __/
| .__/ \__, | |_| |_| |_| |_| |_|
|_| |___/
Enter the code depicted in ASCII art style.