Release of Information
In order for Campbell University's Student Success office to provide disability services, you must, in accordance with college policy and your right to confidentiality, authorize this release of information. The release form authorizes the Student Success staff to disclose your status as an individual with a disability and approved accommodations, as appropriate and useful to the individuals that you list here.
Student ID Number
Main Campus (Buies Creek)
Campbell email address
Confirm email address
Phone where you can be reached should we have questions.
Department or Program (major)
Please select the term you are requesting Letters of Accommodation for at this time. Please note that you must complete a separate form for each term.
Summer 2017 - Adult & Online Education
Summer 2017 - Main Campus (Buies Creek)
Fall 2017 - Semester - Main Campus (Buies Creek)
Fall 2017 - Term 1 - Adult & Online Education
Fall 2017 - Term 2 - Adult & Online Education
I indicate by submitting this release that I am giving consent to the Campbell University Student Success staff to discuss my accommodations with the following individuals for the semester indicated above.
Graduate/Professional students enrolled in CPHS programs that use ExamSoft also give permission for testing accommodation information to be shared with the ExamSoft Administrator when they submit this form. Other program staff and directors/deans who may also be involved in the provision of accommodations are also included as needed.
Adult and Online Education students also give permission for their campus ADA coordinator to be informed of their accommodations when they submit this form.
**Please list all faculty you would like notified followed by the course they will be teaching. WebAccess has this information if you are unsure of names or course numbers.
Peterman, ENGL 204
Jonas, CHRS 125
Tillman, Rural Health
If you need to request changes to your accommodation plan, please describe your concerns below. Leave blank if you do not need to request changes.
Signature: By typing your full legal name in the space below, you are authorizing Campbell University's Student Success staff to complete your request for letters of accommodation and to discuss your accommodations with the persons listed on this form for the duration of the semester indicated. Student Success does not release your diagnosis or medical documentation without an additional release form that is available in our office. This release is for your approved accommodations only.
Please email firstname.lastname@example.org if you have questions.
Do Not Fill This Out