Release of Information Form for Academics

University of Louisiana at Monroe
Office of Student Accessibility Services

PERMISSION TO RELEASE INFORMATION

I give my permission to the Office of Student Accessibility Services to release my accommodation 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.