Authorization for Release of Confidential Information Maintained by Disabled Student Programs & Services, Riverside Community College District

I hereby authorize and request Disabled Student Programs & Services to release the following information about me:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
 
I understand that I can revoke this consent at any time prior to the release of this information. This consent will expire in one year (365 days) unless otherwise specified below.
 
Expiration Date: _________________________________________
 
Release the above information to:
___________________________________________________________________________________________
Name of Agency:
 
___________________________________________________________________________________________
Address, City, State & Zip:
 
___________________________________________________________________________________________
Name & Title to which information is being released:
 

 
 
_______________________________________
Student's Name:
 
_______________________________________
Maiden Name or Other Used:
 
_______________________________________
Social Security No:
 
_______________________________________
Student ID No:
 
_______________________________________
Date of Birth:
 
________________________________________
Student Signature & Date:
 
________________________________________
Parent or Guardian Signature (required for student under 18 years of age:
 
A photocopy of this is as valid as the original.