CONFIDENTIAL

To: Dean of Student Services, Flint Hills Technical College


I hereby give the Dean of Student Services at Flint Hills Technical College, permission to share information with the following persons/agencies:

ALL AGENCIES AND/OR PERSONS WITH A LEGITIMATE EDUCATIONAL NEED TO KNOW.

Or, check specific groups below with whom we may share information.

All Faculty
Specific Faculty Only (Please list names in boxes below)





Academic Advisors
Other College Personnel
Previous Educational Institutions
Medical/Counseling Facilities
Recordings for the Blind
Department of Rehabilitation
Other

I understand that I must provide medical or other diagnostic documentation of my disability and limitations, prepared by a qualified physician, psychologist or professional which states the parameters of my disability, to the Dean of Student Services.

Name:
Last Name:
First Name:
Middle Name:

I verify that the information submitted in this form is true and accurate

Signature (please type your name):
Date:	Date and timeNow