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Release of information for Mid-Plains Community College

Disability Service Office

I, guest guest, hereby grant permission to the Disability Service Office(s) of Mid-Plains Community College to release academic, social, psychological, medical, vocational, or other confidential information to appropriate MPCC Staff.

This information will be used professionally for the purpose(s) of documentation of a disability and/or provision of support services or accommodation.

Student Signature (Type Name)

Date