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I give my consent for this confidential information to be shared verbally or in writing between BMCC Disability Services and the following persons and/or agencies. In addition please provide the Name(s) & Contact Number(s) in the text field below your selection(s). If an emergency contact is selected, is there someone you wish BMCC Disability Services to notify?:
I understand that each person listed above will be informed that the confidentiality of this information is protected by state laws (ORS 192.500 and ORS 179.505) and federal law (PL93-380, the Federal Family Education Rights & Privacy Act of 1974). The information shared with them is for their knowledge only and will not be shared with others unless I am informed or give my consent. Consent may be withdrawn by written notice.
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