The student named below has requested services/accommodations through the Disabled Student Programs and Services Offices. In order to assist him/her, we must have the information checked below.

Treating Physician/Verifying Professional: _________________________________________________________________
Name of Business/Clinic: __________________________________________________ Phone #: ___________________
Address: _______________________________________________________________ City: ______________________
State: ________ Zip Code: __________________
Return to :

Attention: Disabled Program Specialist
Disabled Student Programs and Services
College of the Redwoods, Del Norte
883 W. Washington Blvd.
Crescent City, CA 95531

Name of Student:_______________________________________ *SSN/ID#: __________________
Other Names Used: _____________________________________ Date of Birth: ________________

I authorize the release of information from my Treating Physician/Verifying Professional regarding my disability(ies) to College of the Redwoods Disabled Student Programs and Services (DSPS). All information will be kept confidential and maintained as a part of my records with the California Community College DSPS Office. This authorization shall remain in effect until revoked in writing by the undersigned. I give permission for DSPS professional(s) to discuss my disability with other professionals who have a legitimate educational need to know. I authorize the release of information to include one or more of the following records identified below:

· Verification of disability signed by an appropriate medical practitioner or psychologist.
· As Appropriate to the Verification:
Psychological Testing and Psycheducational/evaluation results/medical reports.
Learning Disability assessment including WAIS-R or WAIS-III, WJR RAW and standard scores.
Audiology and speech/language pathology reports.
Vocational Rehabilitation Plan and “Certificate of Eligibility”
School Transcripts
Individual Education Plan (IEP)
Other ________________________________________________________________________

Signature of Student: ___________________________________________ Date: ______________
Signature of Parent or Guardian: __________________________________ Date: ______________
(Required for student under 18 years of age).

*The Community College District uses the information requested on this form for the purpose of determining a student's eligibility to receive authorized special services provided by the Disabled Students Programs and Services (DSP&S) Program. Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the Chancellor´s Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232 (g)). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. § 552a, note), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000 et seq.