Disability Services Consent to Share Information

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Please correct the field(s) marked in red below:

BMCC ID:
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First Name:
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Last Name:
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Phone Number:
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Date of Birth:
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If you consent to have information regarding your disability shared between BMCC Disability Services staff and specific individuals for the purpose of assisting them in understanding any or all of the following:  abilities and disabilities, request for accommodations, health and safety needs, strategies that are effective, and academic success please input your name here:
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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 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?:
Name(s) & Contact Number(s) for previous selection(s):
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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  Consent may be withdrawn by written notice.

  1. To receive a copy of your submission, please fill out your email address below and submit.