Chaminade University of Honolulu Kōkua ʻIke: Center for Student Learning

3140 Waialae Ave. Student Support Services Building Honolulu, HI 96816

P: 808.739.8305 E: ada@chaminade.edu

AUTHORIZED RELEASE FORM

(Please print)

Name____________________________________________ Birth Date_________________________________

Permanent address__________________________________ Student ID #______________________________

_________________________________________________ Area Code & Phone __________________________

Email address__________________________________________________________________________________

Please note that there are two ways information provided by you regarding a disability may be used.
1. In order to verify to those in position to make accommodations and providing assistance to you for your
disability to the extent deemed appropriate.
2. For purposes of consulting an outside educational expert to help us determine the best way we can
accommodate your needs.
This form is to obtain your permission to release this information on a need-to-know basis to individuals serving
one of these purposes. Please indicate below WITH YOUR INITIALS those whom you are authorizing a release of
information. The nature of your disability will NOT be disclosed without prior authorization unless you file legal
action again the University, by court order, or if you pose a threat to self or others. Please note that the degree or
manner in which the University can accommodate your needs may be limited through restrictions placed on the
institution or if it causes undue hardship for the University.

_____Faculty (notification for each faculty member, whom you select each semester, will receive indication of the
accommodations agreed upon by you and the University to aid you; Faculty will not receive copies of
medical or diagnostic records. Faculty may consult Kōkua ʻIke: Center for Student Learning (Kōkua ʻIke) for
further clarification once they have received notification.)
_____Residence Hall Staff (so accommodations within residence halls or campus apartments may be better facilitated; Staff
will not receive copies of medical or diagnostic records. Staff may consult with Kōkua ʻIke for further
clarification once they have received notification.)
_____Advising Office (so accommodations in scheduling and course load may be made; Staff will not receive copies of
medical or diagnostic records. Staff may consult with Kōkua ʻIke for further clarification once they have
received notification.)
_____Testing Center and Tutoring Services (so assistance via tutoring, testing accommodations can be made, if
appropriate; Staff will not receive copies of medical or diagnostic records. Staff may consult with the Kōkua
ʻIke for further clarification once they have received notification.)
_____Other (specify)____________________________________________________________________________

In order to allow Chaminade University to accommodate my declared disability, I hereby authorize the Kōkua ʻIke
to release information regarding my disability in the manner and to the extent as I have indicated above:

Student Signature_________________________________________________* Date________________________

This release shall remain in effect for the duration of my career at Chaminade University, unless I notify the Kōkua
ʻIke in writing that I wish to modify or rescind it.

*IF THE STUDENT IS UNDER 18 YEARS OLD, A PARENTAL/GUARDIAN SIGNATURE IS ALSO REQUIRED:

_____________________________________________________________ Date_________________________

Revised 08.06.2020