Disability Support Services (DSS) is committed to protecting the confidentiality of individuals served through the office. DSS records will not be disclosed to others unless there is written permission to do so, or unless the law authorizes or compels us to do so. The purpose of this form is to guide DSS staff members in communicating with others regarding disability documentation, academic adjustments, and/or auxiliary aids.

Please indicate on this form, by placing your initials next to any person or group of people below, with whom you give DSS permission to release information to or receive information from regarding your disability, documentation of your disability, academic adjustments, auxiliary aids, and/or academic progress.

____  Current or future quarter faculty
____  Dept. of Vocational Rehabilitation
____  Admissions/Registration
____  Dept. of Services for the Blind
____  Financial Aid/Veterans
____  Sponsored Programs
____  Health Services/Security
____  Columbia River Mental Health
____  Tutoring Center, Writing Center
____  Math Lab
____  Other __________________________________________________  

Specific Authorizations

Drug and Alcohol: I understand that my records may contain information regarding diagnosis or treatment for drug or alcohol abuse. I give my specific authorization for these records to be released. Initial _____

AIDS/HIV: I understand that my records may contain information regarding testing, diagnosis, or treatment of AIDS/HIV, or of sexually transmitted diseases. I give my specific authorization for these records to be released. Initial _____

I understand that I may cancel this authorization at any time, except to the extent that action has already been taken. Unless cancelled earlier by me, this authorization will expire two years from date of signature below. A facsimile of this form will be considered valid.

  ______________________________________________________________
  Signature                                                                               Date

  ______________________________________________________________
  Print Name                                                   Clark College student ID number