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:

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.

      _           _____                 _____
     | | __   __ |__  / __   __ __  __ |__  /
  _  | | \ \ / /   / /  \ \ / / \ \/ /   / / 
 | |_| |  \ V /   / /_   \ V /   >  <   / /_ 
  \___/    \_/   /____|   \_/   /_/\_\ /____|

Enter the code above *

Enter the code depicted in ASCII art style.