Release of Information Request

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Release of Information Request

This Release of Information Request Form is used to send and receive your personal information.

If you would like Skyline EAC to SEND your information:

Skyline EAC will send documents within the San Mateo Community College District to our sister Disability Resource Centers so that you may register for services at CSM or Canada College. Each college is separate and independent so you will need to set up accommodations at each college where you are enrolled in classes. To complete the accommodation process at our sister colleges, you will need to submit an application for services, have an intake appointment, and complete an Academic Accommodation Plan.
Due to privacy concerns, Skyline EAC will not send documents to any other 3rd party (school, organization, or person) but will release documents to your official school email account (@my.smccd.edu) so that you can forward them as needed.
You may also allow Skyline EAC to communicate with a person or organization of your choice.

If you would like Skyline EAC to RECEIVE your information:

Please submit a Skyline EAC Application for Services as well as your Release of Information form. The Skyline EAC intake process requires an application for service, disability documentation, intake appointment, and a signed Academic Accommodation Plan.

Name*

First Name

Last Name

G#*

Email*

my.smccd.edu email address only

I am requesting the following documents: *

Disability verification (IEP, 504 Plan, Psycho Ed, Dr's letter, LD eligibility, etc) Accommodation letter Academic Accommodation Plan Check All

Skyline EAC needs disability verification to determine eligibility for accommodations

Complete this section if you are a former or current Skyline EAC student and you would like Skyline to SEND your information.

I would like Skyline College to provide my documentation to the following college

College of San Mateo (CSM) Canada College

By checking a box here you are authorizing Skyline College EAC to share your documents with listed college

I would like Skyline EAC to provide me with my documents

Skyline EAC will send documents to you so you may forward to another college or individual

By checking a box here you are authorizing Skyline College EAC to share your documents to your my.smccd.edu email address

I am allowing the EAC to communicate with the following programs:

Promise Scholars Program EOPS TRIO Veterans

Other:

Check all that apply

Complete this section if you would like Skyline EAC to RECEIVE documents on your behalf.

I would like the following college to provide my documentation to Skyline College

College of San Mateo (CSM) Canada College

By checking a box here you are authorizing CSM or Canada DRC to share your documents with Skyline College EAC

I would like the following organization/person to provide my documentation to Skyline College:

Organization Address

Address Line 1

Address Line 2

City

State

ZIP Code

Organization Phone

Organization Email

I understand that my signature authorizes this consent and becomes effective immediately.

Signature *

[clear]

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If unable to sign, please type your consent.

First Name

Last Name