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

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 |  _ <  | |___  | |\  | | (_) | | | | | | |___ 
 |_| \_\  \____| |_| \_|  \___/  |_| |_| |_____|

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