(2/4/2011)
INFORMATION RELEASE FORM
Pepperdine University
Disability Services Office
TCC 264
(310) 506-6500
Please Print or Type
STUDENT NAME
Last First M.I.
CAMPUS WIDE I.D. #
CAMPUS BOX # (or off campus local address where you receive mail)
CITY STATE
ZIP CODE
PHONE #
EMAIL ADDRESS:
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE #
Release of Information
I hereby give permission to the staff of the Disability Services Office to discuss my
accommodation needs with Pepperdine University faculty and/or staff who request such
information.
I also give permission for DSO staff to speak with the following individuals outside of
Pepperdine University (this could be a parent or other family member, physician,
psychologist, etc):
_________________ ___________________ __________________
Name Relationship to student Phone/Email
__________________ ___________________ __________________
Name Relationship to student Phone/Email
_______________________________ _______________
Student initials Date
Additional Notes/Comments: ______________________________________________
_____________________________________________________________________
CONFIDENTIAL
