Permission to Release and Exchange Information

  • I give Nashua Community College’s Disability Services Coordinator permission to discuss pertinent educational, psychological, and/or medical records for the purpose of providing accessibility/disability support services at NCC. This includes contact by e-mail, fax, telephone, and in person.

    NCC may release/exchange information with the individuals listed below:

    Note: You can include parents, siblings, significant others, doctors, counselors, Voc Rehab counselors, etc.

  • OR
  • I understand and agree that the information will be released effective until the NCC Disability Services Coordinator has received written notice to revoke this form.

    You can revise the Permission to Release and Exchange Information form at any time by submitting an updated, signed form.

  • Terms are effective upon date received by NCC Disability Services Office.

    A copy of the Permission to Release & Exchange Information shall have the same force as the original.

  • This field is for validation purposes and should be left unchanged.