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.