Gallaudet University
The Center of Academic Programs and Student Services (CAPSS)

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Release Information Form

I, , give permission to the Office for Students with Disabilities to obtain information from and/or release information to:

Academic Advising

Admissions Office

Audiology Department

Career Center Staff

Gallaudet University Faculty/Staff

Learning Disability Diagnostician

Medical Personnel

Student Health Services

Tutorial Center Staff

University Couneling Center

Vocational Rehabilitation Counselor 

Other - Specify Title:

 

Name: 

Address: 

Fax: 

Phone: 

   

Student Signature:

Student E-Mail:

(Typing your name is equal to your signature agreeing to what you have filled in).

 

Date:

   

Staff Signature:

Staff E-Mail:

(Typing your name is equal to your signature agreeing to what you have read).

 

Date:

   

Thank  You.

For more information or assistance, contact:

College of Liberal Arts, Sciences, and Technologies
Center for Academic Programs and Student Services (CAPSS)
Gallaudet University 
Student Academic Center Room 1220
800 Florida Ave. NE
Washington, D.C.20002-3659
(202) 651-5256 (V/TTY)
oswd@gallaudet.edu