Authorization to Release Information to SAS

This authorization will be in force while I am an applicant of or student at UTRGV unless revoked by written notice. I further authorize that a photocopy of this authorization be fully acceptable as an original.

This requested information will be used to help determine the student’s eligibility for services from the Student Accessibility Services Office. The confidentiality of this information will be protected under FERPA (Family Educational Rights and Privacy Act of 1974).

Student Information First Name (Required) Format: First Name (Special instructions) Last Name (Required) Format: Last Name Email (Required) Format: jane.doe@utrgv.edu Date of Birth (Required) Format: mm/dd/yyyy Student ID (Required) Format: UTRGV ID Number I (the above-named student/applicant) request and authorize (Required) Format: (Name of individual)

to release to UTRGV the following information: (Required) Full and Individual Evaluation/Psychological Evaluation
Recommended Accommodations
Medical Information (Diagnosis/Functional Limitations)

Dates of treatment or attendance requested (from): (Required) Format: mm/dd/yyyy Dates of treatment or attendance requested (to): (Required) Format: mm/dd/yyyy Date of Authorization (Required) Format: mm/dd/yyyy Parent or Guardian Name if Applicable Date Format: mm/dd/yyyy

Accessibility Office Location

Send information to the designated UTRGV SAS office: (Required) Edinburg Campus - 1201 West University Dr. University Center 108 Edinburg, TX 78539
Brownsville Campus - One West University Blvd. Cortez Hall 129 Brownsville, TX 78520

The University of Texas Rio Grande Valley

Student Accessibility Services Office of Student Life and the Dean of Students

Authorization to Release Information to SAS