Request for Release of SRJC/Disability Resources Records

Name*

First Name

Last Name

Student ID Number*

Email*

I am requesting the following records: (check all that apply)*

Academic Accommodation Plan, including list of accommodations and services Verification of Disability

Other:

Please fill-in all that apply:

Email my records as a PDF to:

Fax my records to:

Mail my records to:

Address Line 1

Address Line 2

City

State

ZIP Code

I will pick up my records. Please contact me at:

I understand that only SRJC documents can be released. High School IEP's or diagnostic reports done by other professionals cannot be released. I need to request those from the person or organization that originally created them.

While SRJC and Disability Resources is working remotely, these requests may take up to 2 weeks to process. Thank you for your patience.

Student Signature*

[clear]

Use your mouse or finger to draw your signature above

Date:*

Signature of Parent/Guardian if student is under 18

[clear]

Use your mouse or finger to draw your signature above

Date:

AAP/Accommodations

Document released Document does not exist

Verification of Disability

Document released Document does not exist

For Office Use Only

DRD is unable to release third-party documents. Please contact them directly for copies.

DSPS Coordinator:

[clear]

Use your mouse or finger to draw your signature above

Date/Time