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.

                  ___           ___   __     __
   ___    __ _   / _ \   ____  / _ \  \ \   / /
  / __|  / _` | | | | | |_  / | | | |  \ \ / / 
 | (__  | (_| | | |_| |  / /  | |_| |   \ V /  
  \___|  \__, |  \__\_\ /___|  \__\_\    \_/   
            |_|

Enter the code above *

Enter the code depicted in ASCII art style.