Academic Advising

Informed Consent Request for Academic Accommodation

Request for Accommodations:

I, , give my permission to the Academic Advising Office staff to share necessary information with relevant members of the faculty, administration, and staff of Clark University.

I understand the sole purpose of this is to help me with my program of study at Clark University. Any information that is shared will be kept confidential and used only for the stated purpose.

I also understand that this release of information can be changed or revoked by me at any time. Specifically, I would like to request that the following faculty members receive memos of accommodations for the semester indicated below.

Semester:

(e.g. Fall 2011)

Faculty Name	Department	Course Title and Course Number

	Yes, I give my permission to share information about my disability with my faculty adviser.
	No, I do not give my permissions to share information about my disability with my faculty adviser.