Release of Disability Information

I, ________________________________________, authorize Andrea Hojnacki, Disabilities Specialist or Linda Larkin, Director of Academic Services to release information pertinent to accommodations requested contained in my disability documentation to my instructor(s) at Charter Oak State College or to a testing company such as ETS if I request accommodations for standardized testing.
I, ________________________________________, authorize Andrea Hojnacki, Disabilities Specialist, or Linda Larkin, Director of Academic Services to seek further information from my documentation provider to further clarify requested accommodations.
By signing below, I consent to the release of the personally identifiable student information specified above to the individuals listed above.

This consent shall remain in effect through (choose one):

□ Entire duration of enrollment with Charter Oak State College

□ Academic Year (specify): ___________________________

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Student Signature							   Date 

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Student ID #

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Disability Specialist 							   Date