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 /   | | | (__    / /  
 /_/   \_\ |___/    \_/    |_|  \___|  /_/

Enter the code above *

Enter the code depicted in ASCII art style.