Center for Student Success
Village Residence Hall
Ground Floor
Release of Disabilities Information
Full Name: __________________________________________
_X__Fall
__X__Spring ____Summer
Year 2016-2017
ID __________________________
Major _________________________
I have provided Anderson University with a recent professional assessment or verification of my learning
or physical disability. I have discussed this information with the staff of the Center for Student Success
and now request that the Center for Student Success notify the following Anderson University officials
of my disability and needed adjustments and modifications:
Check all that apply:
_____Academic Advisor (Name: ______________________________________)
_____Dean of my college (or designee)
_____Counseling Services
_____Residence Life
_____Financial Aid
_____Career Services
_____Other official (Name: __________________________________________)
____ All of my instructors for fall and spring
____Only those instructors/courses named below:
Instructor
Course
_____________________________________________________________
_____________________________________________________________
I understand that my permanent file at Anderson University is available only to those university officials
with a legitimate educational interest in that information.
I also understand that I must give permission for this release of information EACH academic year of my
enrollment at Anderson University.
_____________________________________
Signature
_______________________
Date