1.         I __________________________ (print name), understand that communications and records relating to my identity, diagnosis, prognosis, or consultation with ODS are confidential.

2.         I authorize ODS to exchange information and/or records regarding my identity, diagnosis, prognosis, or consultation as necessary with the following staff members:

        a.     Office of the Dean of Studies

        b.     Office of Financial Aid

        c.      Office of Safety and Security

        d.     Office of Residential Life and Housing

        e.     Student Counseling Services/Health Services

        f.     My instructors

        g.     Other___________________________

3.         I understand that a refusal to grant consent to these disclosures will not jeopardize any right to obtain present or future services from ODS.  I also understand that I may withdraw consent to this disclosure at any time by sending written notice of revocation to ODS in 105 Hewitt.

______________                              ____________________

Date                                              Signature

ODS 8/08