Uc San Diego Consent To Release Information Form (Page 2 of 2) in pdf

Uc San Diego Consent To Release Information Form Page 2

STOP AND READ CAREFULLY!

Notice of Exception to Rights of Confidentiality

And

UC San Diego Student Conduct Code/Principles of Community

I understand that all information disclosed within the Office for Students with Disabilities (OSD) is confidential

and will not be discussed with anyone outside the OSD without my written consent as indicated above.

However, exceptions to this will be made under the following conditions:

1. When a student engages or threatens to engage in behavior which poses a danger of causing physical

harm to self or others.

2. When a student engages or threatens to engage in behavior which would cause significant property

damage OR directly and substantially impede the lawful activities of others.

3. When a student engages or threatens to engage in legal action against UC San Diego and/or UC

Regents.

By signing below, I acknowledge that I will adhere to the UCSD Student Conduct Code and Principles of

Community. Regulations regarding Student Conduct may be found here:

students/student-life/_organizations/student-conduct/regulations/index.html

or at the Office of Student

Conduct, Student Services Center, 5

Floor, Suite 510; 858.534.6225. I further acknowledge that I have been

provided with a copy of the UCSD Principles of Community.

__________________________________________________________________________________________

Signature

Date

Consent to Release Information Form 04.01.15

Uc San Diego Consent To Release Information Form Page 2