Accommodation Release of Information Form

University of Louisiana at Monroe
Office of Student Accessibility Services

PERMISSION TO RELEASE INFORMATION

I agree *

I give my permission to the Office of Student Accessibility Services to release my accommodation information to my instructors and/ or required staff for the related information

What area of accommodation are you approving information release for? (Select all that apply )

Academics

Residential

Elevator Access

ESA

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.

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