Release of Information to Marquette University Faculty/Staff
I have been informed of the policy regarding confidentiality and the release of information from my file at the
Office of Disability Services (ODS). I give my permission to ODS to release information from my file to use in a
confidential manner per the following (check one):
______ with appropriate University faculty and officials who have a legitimate educational
interest while I am a student at Marquette.
or
______ only with the designated individuals listed below:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
I give my consent for the entire ________________________________Academic Year.
This consent may be revoked
at any time upon written request.
_________________________________________________________________________
Student Signature / Date
_________________________________________________________________________
Printed Name / MUID
_________________________________________________________________________
Office of Disability Services Representative / Date
Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013