Consent form

Name

First Name

Last Name

Date/Time

SSN

Date of Birth

I hereby authorize Northeast Mississippi Community College's Office of Disability Accommodations to communicate with the following: (please check all that apply)

Parents NEMCC Faculty/Staff, on campus services (i.e. Student Services, Housing, etc.) Off Campus Services (i.e. Professionals, Schools, Vocational Rehabilitation, etc.)

Communication as denoted above may include obtaining and/or releasing student's historical and/or current information regarding assessment, diagnosis, needs, recommendations, treatment, prior services, academic records, performance, or information that may relate to accommodating students' needs on NEMCC's campus. This consent form will be valid until revoked by student. A photocopy of the original consent form shall be as valid as the original consent form.

In compliance with Title VI of the Civil Rights Act of 1964; Title IX, Educational Amendments of 1972 of the Higher Education Act; and, Section 504 of the Rehabilitation Act of 1973, as amended, the Board of Trustees of Northeast Mississippi Community College has adopted this policy assuring that no one shall, on the grounds of race, color, age, national origin, or sex, be excluded from participating in, be denied the benefits of, or otherwise be subjected to discrimination in any program or activity of the College. Northeast Mississippi Community College adheres to the principle of equal educational and employment opportunity without regard to race, sex, age, color, creed, or national origin. This policy includes the qualified handicapped and extends to all programs and activities supported by the College. The Section 504 Coordinator is Leigh Ann Stewart, Wright Hall (662)720-7192 and the Title IX Coordinator is Liz Roark, (662)720-7223.

Student requiring services

[clear]

Use your mouse or finger to draw your signature above