Disability and Accommodation Disclosure Release

Disability and Accommodation Disclosure Release

Academic Affairs ADA Services Office
I hereby authorize Friends University, its agents, employees, and assignees, to release or disseminate any information provided to it regarding my accommodations and disability or medical condition including, but not limited to, any information provided to Friends University in the form of medical records or correspondence.
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Current School Term *
i.e Spring 2020, Fall 2020, etc.
Student ID#
Signature *

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Should be Empty: