Accessibility Services

Authorization to Release Information

Name: Student ID
Address:
Street City State Zip Code

Phone Number: E-Mail Address:

I authorize Accessibility Services to communicate concerning my accommodations as needed with the following:
(PLACE YOUR INITIALS TO THE LEFT OF EACH ITEM APPROVED)

Office of Vocational Rehabilitation

Spalding University Instructors/Dean/Staff
Spalding Counseling Center

Other (please specify):

I understand that I may withdraw this permission to release information at any time. I must present a request in
written form to void my authorization. At that time, information that has not already been released will be
withheld from the mentioned parties. I also understand that academic adjustments are not retroactive. It is my
responsibility to submit my academic adjustment letter and refer my faculty to the academic adjustments I will be
implementing.

Authorization remains in effect for 18-19 academic year.

Student Signature Date

Coordinator Accessibility Services Signature Date

RECORDS WILL NOT BE RELEASED WITHOUT PRIOR CONSENT.

Request for accommodations may take up to a period of 6 weeks, depending on the availability of documentation,
and the amount of time needed to research and identify the most effective and appropriate accommodations.
Appropriate accommodations will afford the student access for academic achievement without impinging upon the
academic integrity of the courses taken. For further information on accommodations please visit the website for
the Association on Higher Education and Disability. http://www.ahead.org/