3140 Waialae Avenue Student Support Services Bldg Honolulu, HI 96816-1578

P: 808-739-8305 E: ada@chaminade.edu

CHAMINADE UNIVERSITY OF HONOLULU

KŌKUA ʻIKE: CENTER FOR STUDENT LEARNING
RELEASE INFORMATION CONSENT FORM

Please place your INITIALS next to all that apply:

I, ________________________ (Full Name of Client) hereby, give consent to:

____ release information
____ obtain information

to/from ___________________________________________________________________________
___Chaminade University of Honolulu’s Kōkua ʻIke: Center for Student Learning ___________

The following information can be released: (Place INITIALS next to all that apply)

_____ Records (EXCLUDING progress notes)

_____ Medical/Clinical Records (for ADA)
_____ Psychiatric Reports for ADA
_____ School Records for ADA
_____ Information of my attendance here but EXCLUDES any content of appointments
_____ General information regarding my progress
_____ Other (need to specify)__________________________________________________________
__________________________________________________________________________________

My signature below attests to the fact that I have read and understood the above information in
entirety. I have also discussed any questions with my counselor and all of my questions have been
answered to my satisfaction. I understand that this consent is valid as long as I am a student at
Chaminade University of Honolulu. If I would like to revoke this agreement, I will submit a letter to
CUH Kōkua ʻIke: Center for Student Learning regarding this matter.

Printed Name of Client________________________________________________________________

Signature of Client_________________________________________________ Date______________

Parent(s) or Guardian(s)
Signature_______________________________________________________ Date______________
(If under 18 years old)

Tutor Coordinator Signature ________________________________________ Date______________

Revised 08.05.2020