Disability Services Release of Information Form

Student Disability Services (SDS) is committed to ensuring that student information is maintained confidentially as required or permitted by law. Any information collected is used for the benefit of the student. This information may include psycho-educational testing, grades, biographical history, disability information, and case notes.

For more information regarding confidentiality and release of information, please visit the Penn State Educational Equity page.

If you are unable to access this form, please contact your disability specialist.

I, the above named person, understand that upon initiating services from Student Disability Resources (SDR), SDR and University officials, who under FERPA (Family Educational Rights and Privacy Act) have legitimate educational interest, may mutually exchange confidential information pertaining to me in an effort to coordinate my SDR academic adjustments, auxiliary aids, and services. SDR adheres to FERPA confidentiality standards in safeguarding medical information and disability status and will exchange information with the sole purpose of coordinating services, to include

  • Request, receive, and discuss documentation for the purpose of determining program eligibility and planning appropriate academic adjustments, auxiliary aids, and services; and
  • Share with appropriate members of the administration, faculty, and staff at Penn State any applicable information related to academic adjustments, auxiliary aids, and services.

In addition to University officials defined by FERPA, I authorize SDR to mutually exchange confidential information pertaining to me to coordinate SDR services with the following health care entities:

(include name, type of provider, & contact information)

I understand that all FERPA rights belonged to my parent(s) or guardian(s) prior to my reaching the age of 18 or beginning to attend a post-secondary institution. Per Penn State policy, FERPA rights now solely belong to me, effective the first day of classes as a newly admitted student scheduled for at least one course. Mutual exchange of information with my parent(s), guardian(s), or any other family member(s) is at my discretion, and I agree with the following (you must check one of the boxes below): 

(include name(s), relationship to you, & contact information)
I understand that this authorization is valid from the date of signing until the conclusion of my enrollment at Penn State, and I have the right to cancel this authorization, in writing, at any time.