Consent to Release Information Form

Waiver of Confidentiality Form for Person with Disability

All information that has been gathered on a person is personal and private, and you are not required to release this information. Such information cannot be released without authorized written permission, except as required by law.

PERSON WITH DISABILITY:

Name:*

Date of Birth:*

Address:*

City:*

State:*

Zip:*

AUTHORIZED REPRESENTATIVE (If Applicable):

Name:

Address:

City

State:

Zip

I understand that the information in the record of the person above is considered personal and private. However,

I GIVE MY PERMISSION FOR:

The Office of Disability Services

615 City Park Ave

New Orleans, LA 70119

TO RELEASE TO:

Delgado's Faculty & Staff

615 City Park Ave

New Orleans, LA 70119

THE FOLLOWING SPECIFIC INFORMATION: Academic accommodations/Academic performance

TO BE RELEASED FOR THE SPECIFIC PURPOSE(S) OF: Reasonable accommodations

My permission to release this information will expire: Upon Graduation

I understand that my permission may be cancelled at any time except when the information has already been released.*type your full name as a digital signature

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Consent to Release Information Form