ࡱ> CGB  l(bjbj :.x_x_( &&&&&:::8rL:0]T,5777777$![E&[&&:&&55 N|(!0@"?@",@"&@[[@"X : Accessibility Services Release of Personal Information Waiver Student Name (First, Middle, Last):  FORMTEXT       Address (include postal code): FORMTEXT       Home Phone (with area code):  FORMTEXT       Work Phone (with area code):  FORMTEXT       Email: FORMTEXT       I hereby authorize Accessibility Services to release the following personal information (please check all that apply):  FORMCHECKBOX  Psychoeducational Assessment  FORMCHECKBOX  Audiological Report  FORMCHECKBOX  Academic Accommodations  FORMCHECKBOX  Neuro-Psychological Assessment  FORMCHECKBOX  Ophthalmology Report o  FORMCHECKBOX  Academic Record  FORMCHECKBOX  Psychiatric Information  FORMCHECKBOX  Medical Documentation  FORMCHECKBOX  Funding information/status  FORMCHECKBOX  Other (Please specify): FORMTEXT       This information may be released to the following institution/individual:  FORMTEXT       Student Signature:  FORMTEXT       Date (mm/dd/yy,.|~ , . 0 D µ¤lllZllP褗hWOCJOJQJ#h h CJOJQJmHnHu,jh h CJOJQJUmHnHu'jh h CJOJQJUh h CJOJQJ!jh h CJOJQJUh hgCJOJQJh hAhCJOJQJh hAh5CJOJQJh hWOOJQJh hWOCJOJQJh hAhOJQJ.|~V X   R T B D F H D F HJ^` &d P gdAh `^``gd gdWO$a$gdAhD F H J L N P R T V X l          ڹڬڬڬwj`h CJOJQJh hAhCJOJQJ'j\h h CJOJQJU'jh h CJOJQJUh hWOCJOJQJh h CJOJQJhWOCJOJQJ,jh h CJOJQJUmHnHu!jh h CJOJQJU'jth h CJOJQJU% * , @ B D F H J L N P R T z   > @ B D F b ⪪՝󝁏q^Oh hAhCJOJQJaJ%jh hAhCJOJQJUaJh hWO5CJOJQJaJh hWO5CJOJQJh hAh5CJOJQJh hAhCJOJQJ,jh h CJOJQJUmHnHu'jh h CJOJQJUh h CJOJQJ!jh h CJOJQJUh hWOCJOJQJb d f h    F H J f h j l ǸǢǸnjָ{eǸOָ+jh hAhCJOJQJUaJ+jh hAhCJOJQJUaJ h hWOCJOJQJ^JaJ+j,h hAhCJOJQJUaJ+jh hAhCJOJQJUaJh hWOCJOJQJaJh hAhCJOJQJaJ%jh hAhCJOJQJUaJ+jDh hAhCJOJQJUaJ   " D F H d f h  HѾ∾r⾯\⾯F+jh hAhCJOJQJUaJ+jph hAhCJOJQJUaJ+jh hAhCJOJQJUaJ h hWOCJOJQJ^JaJ+jh hAhCJOJQJUaJh hAhCJOJQJaJ%jh hAhCJOJQJUaJ h hWOCJOJQJ^JaJh hWOCJOJQJaJh hgCJOJQJaJHJLhjln\^`Ϲ񦗁hhhhh[M[h hAh5CJOJQJh hAhCJOJQJ0jh h CJOJQJUaJmHnHu+jh h CJOJQJUaJh h CJOJQJaJ%jh h CJOJQJUaJ+jXh hAhCJOJQJUaJh hAhCJOJQJaJ%jh hAhCJOJQJUaJh hWOCJOJQJaJ`bvxz|~"""""" """$"&"("*"{ye'j(h h CJOJQJUU'jh h CJOJQJUh hWOCJOJQJh hAhCJOJQJh hgCJOJQJ,jh h CJOJQJUmHnHu'j@h h CJOJQJUh h CJOJQJ!jh h CJOJQJU'."|"#4#,$.$%%P(T(V(Z(\(`(b(f(h(j(l(^gdggdggdWO): FORMTEXT       The completed form may be returned by: E-mail:  HYPERLINK "mailto:asd@athabascau.ca" asd@athabascau.ca Fax: (780) 421-2546 or, Mail: Accessibility Services Athabasca University Peace Hills Trust Tower 1200, 10011  109 Street Edmonton, AB T5J 3S8 Note: This waiver is in effect for a maximum of one year unless the student identifies a shorter period. The personal information collected on this form will be used for the purpose of processing your request to share your personal information as instructed above. It is collected under the Freedom of Information and Protection of Privacy Act of Alberta and will be protected under its provisions. 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