Release Form

I agree to the mutual release and exchange of information between the Ross Center for Disability Services and the person or agency specified below related to my diagnosis, treatment and accommodations.

I understand that information about me may be shared with other faculty and staff of UMass Boston on a need-to-know basis.

Complete the Release Form below

Is this information being released to the person submitting this request?

YesNo

Name of person submitting this form

First Name:

Last Name:

Email:

Person(s) or agency with whom information will be shared

First Name:

Middle Initial:

Last Name:

Email:

If the information will be released to more than one person, list them in the box below:

Title or relationship to student (parent, physician, psychologist, etc...):

Address:

City:

State:

Postal Code:

Phone:

Fax Number:

Student Information

First Name:

Middle Initial:

Last Name:

Email:

Student ID:

Additional Comments

Please add any additional comments below.

Authentication

Checking the box below, confirms the Information you have entered in this form is, to the best of your knowledge true and correct.

The Information I have entered in this form is, to the best of my knowledge true and correct.

Contact Information

UMass Boston

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Release Form

Complete the Release Form below

Name of person submitting this form

Person(s) or agency with whom information will be shared

Student Information

Authentication