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.

  _       _____   ____   __        __  _        
 | |     |_   _| | __ )  \ \      / / (_)   ___ 
 | |       | |   |  _ \   \ \ /\ / /  | |  / _ \
 | |___    | |   | |_) |   \ V  V /   | | |  __/
 |_____|   |_|   |____/     \_/\_/    |_|  \___|

Enter the code above *

Enter the code depicted in ASCII art style.