Housing/Dining/Parking Modification Committee Release

I authorize the Accessibility Resources Center staff and the Housing/Dining/Parking Modification Committee of the University of New Haven to receive and review the documentation of my disability.

The information to be released from my records is as follows:

Information related to my disability including, but not limited to, diagnosis, remediation efforts and academic progress for the purpose of determining my eligibility as a student with a disability and any related reasonable accommodations/services in accordance with state and federal regulations.

I understand that this information shall remain confidential and shall not be further relayed by the committee in any way to any outside person or agency without an additional written authorization by me except as required by law.

By signing this Release of Confidential Information, I release the staff of the Accessibility Resources Center, the members of this committee, the staff of University of New Haven, and its employees, and the person(s) or agency named above from any liability resulting from the release of the information. Furthermore, I understand that I may withdraw this authorization at any time prior to the release of the above information. This authorization, if not withdrawn, is valid until canceled by me in writing. This release form had been read/viewed with me and I understand its content.