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 to other Friends faculty or staff, any information provided to it regarding my accommodations and permanent disability or temporary medical condition including, but not limited to, any information provided to Friends University in the form of medical records or correspondence.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Current School Term*
i.e Spring 2020, Fall 2020, etc.
Student ID#
If you give us permission to answer questions from your emergency contact and/or family member(s) about your accommodations this semester, please list the name(s) and phone number(s) or email(s) here.
Signature*

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