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.
  ____    _       _  _     _      __  __ __   __
| _ \ | | | || | | | \ \/ / \ \ / /
| | | | | | | || |_ | | \ / \ V /
| |_| | | |___ |__ _| | |___ / \ | |
|____/ |_____| |_| |_____| /_/\_\ |_|
Enter the code depicted in ASCII art style.