Uc San Diego Consent To Release Information Form
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2UC SAN DIEGO
OFFICE FOR STUDENTS WITH DISABILITIES (OSD)
PHONE: 858.534.4382 | FAX: 858.534.4650
CONSENT TO RELEASE INFORMATION FORM
Name: _________________________________________
PID# _______________________________________
Initial only one box:
I authorize the Office for Students with Disabilities (OSD) at UC San Diego to communicate with the emergency
contact person and medical providers (listed below) as well as UC San Diego faculty and staff in order to obtain and
release information (written or verbal) regarding my disability and its impact on major life activities, particularly those
which are academic in nature. I understand that I may revoke consent at any time and that this revocation must be
delivered to the OSD in writing during standard University business hours. This consent form will be valid beginning the
date it is signed until the end of the following academic year unless I stipulate otherwise on this form.
I have chosen NOT to complete this form, and I decline to give permission to the OSD to communicate with
anyone on my behalf. In doing so, I understand that the OSD may not be able to support my request for
accommodations.
__________________________________________________________________________________________________
Student Signature
Date of Authorization
_______________________________________________________________________________________________
Emergency Contact Person
Relationship to Student
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
Telephone Numbers (Home/Cell/Work)
_______________________________________________________________________________________________
Fax Number
Email Address
_______________________________________________________________________________________________
Medical Provider
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
Telephone Number
Fax Number
Email Address
_______________________________________________________________________________________________
Medical Provider
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
Telephone Number
Fax Number
Email Address
Consent to Release Information Form 04.01.15
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