Release of Information

Disability Access Center (DAC) is committed to protecting the confidentiality of individuals. While the DAC office must communicate with instructors regarding the implementation of accommodations, DAC 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 DAC 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 DAC permission to release information to or receive information from regarding your disability, documentation of your disability, academic adjustments, auxiliary aids, and/or academic progress.  Authorizing the DAC Office staff to share information with any individual below does not absolve you of your responsibility as a student.  Authorization to share information does not mean that another party can manage your accommodation plan.  You are responsible for your accommodation plan and implementation.

____  Advising
____  Admissions/Registration
____  Financial Aid
____  Health Services/Security
____  Tutoring Center, Writing Center, Math Lab
____  Dept. of Vocational Rehabilitation
____  Dept. of Services for the Blind
____  Dept. of Labor and Industries
____  Running Start
____  Veterans
____  Other __________________________________________________  

Specific Authorizations (applicable only when requesting documentation)

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.

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  Signature                                                                                                                              Date

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  Print Name                                                                                                                          Clark College Student ID Number