DISABILITY SERVICES
INFORMATION RELEASE FORM

I, __________________________ give the Office of Disability Services at East Tennessee State University permission to both obtain and share information/documentation from the following sources:

    A.)    Disability Services
     B.)     Division of Rehabilitation Services
     C.)    ETSU Counseling Center
     D.)    ETSU Faculty
     E.)     ETSU Housing
     F.)     ETSU Public Safety
     G.)    Other
      ________________________________________________
      ________________________________________________
      ________________________________________________

 H.)    Agencies of Practitioners that might have relevant information concerning your case.        _________________________________________________
_________________________________________________
_________________________________________________

 I understand that I have the right to eliminate, by marking through the name, and person/office listed that I do not want information shared with.  I also understand that this request for information is used only for the fulfillment of my educational needs.

Student Signature: ________________________________________   Date: __________

Parent Signature if under 18 years of age: _______________________________________

Disability Services Staff Signature: ____________________________   Date: __________