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NAME_____________________________________________DATE OF BIRTH______________ LAST FIRST M MM/DD/YY ID/SS#________________________________________ PHONE NUMBER (____)___________ ADDRESS______________________________________________________________________STREET CITY ZIP MAIDEN NAME OR OTHER USED_____________________________________________________ LAST FIRST M I, the undersigned, request any appropriate person and/or agency or institution to release information consistent with the Federal Family Educational Rights and Privacy Act of 1974, or other laws, regulations, or policies to this college for the use in educational/vocational planning. All information will be kept confidential and maintained as part of my records with the Services for Individuals with Disabilities office at the college. I authorize the release of information, which may include. [ ] Verification of disability________________________Specific Disability Provider's Name________________________________________________________________ Company______________________________________________________________________ Address_______________________________________________________________________ Phone____________________________________ FAX_______________________________ [ ]Psychological evaluation and test results, include raw scores and educational limitations [ ]Learning disability assessments with educational limitations [ ]Audiology an speech/language pathology reports [ ]Vocational rehabilitation plan, Counselor______________________________________ [ ]Verification of brain injury, ADD, ADHD with educational limitations [ ]Other:________________________________________________________________ I also give permission for Services for Individuals with Disabilities' staff to discuss my educational situation with other professionals who have a legitimate need to know. X____________________________________________________________________ This authorization shall remain in effect during my enrollment or until revoked in writing. _____________________________________________________ ____________________Signature of Student Date _____________________________________________________ ____________________ Signature of Parent or Guardian for Students under 18 years of age Date Services for Individuals with Disabilities FAX:(423) 318-2344 500 South Davy Crockett Parkway Morristown, Tennessee 37813-6899 |