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.