PERMISSION TO RELEASE INFORMATION I give my permission to the ULM Counseling Center to release special need information to my instructors for the ____________ semester. This information is for professional purposes only and is confidential in nature. Date ____________________________________________ Signature________________________________________ Print Name_______________________________________ Social Security Number_____________________________ Date of Birth _____________________________________ Do you want letters sent to all of your professors? Yes No List exceptions: ____________________________________ _________________________________________________ _________________________________________________