Minority Advising Program                                                                                                          

Postsecondary Readiness Enrichment Program                                                                             

Student Support Services                                                                                                                

Upward Bound Program                                                                                                                  

ABAC 21, 2802 Moore Hwy       

Tifton GA 31793-2601

Telephone (229) 386-3489

Fax (229) 386-3579      

RELEASE OF INFORMATION

I, (please print)____________________________, hereby authorize Ms. Cheryl Biggs and/or Ms. Rita Wade, advisors for students with Specific Learning Disabilities, to release all confidential psychological data to the Regents Center for Leaning Disorders (RCLD) for review and evaluation. This process is to determine if I meet the criteria for Learning Disabilities as outlined by the University System of Georgia Board of Regents. I realize that I may be required to have additional testing in order to maintain my eligibility for accommodations for Learning Disabilities. I will accept the recommendations of the Regents Center for Learning Disorders.

_________________________________________________     
Signature                                                                                      
 

___________________
Date