Consent

6SruNTMARYS srNcr rso2 \/ uMVERslrY OneUniversity. OneWorld.Yours. Department Office ATTnNTICCENTRE T 902.420.5452 OF...

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6SruNTMARYS srNcr rso2 \/

uMVERslrY

OneUniversity. OneWorld.Yours.

Department Office ATTnNTICCENTRE T 902.420.5452 OF SUPPORT FORSTUNEru:rS F 902.496.8122 WITH DTSNBTTTTIES

CONSENTFOR RELEASEOF INFORMATION

I herebyfreely give my consentto (Atlantic CentreCounsellor) To releasethe following infonnation: Information containedin my client files kept by The Atlantic Centrreof Supportfor Studentswith Disabilitiesregardingthe supportsand servicesI accessed. I releasethe aboveinforsration confirming my disability to be sentto: Name: Address: *This consent can be withdrown at any time.

(studentsignature)

923 Robie Street . Halifax. Nova Scotia B3H 3C3 . Canada . www.smu.ca

(date)