Wofford College - Wofford Records Release

I request that a copy of the following information contained in my medical record to be :

An unaltered photocopy of this document may be accepted in lieu of the original and I understand that the original will be maintained in my records.

This authorization will remain in effect until .
This authorization will remain in effect until this request is processed.

(By typing my name I acknowledge that this constitutes an electronic signature.)
Date: [None]

If you prefer, you can also download a copy of the Wofford Records Release Form, complete it and mail it to Wofford. Completed forms should be mailed to:

Student Name
Date of birth
W Number
Email address
Cell phone number
Are you a current student?
Starting year at Wofford or graduation year if you have already graduated?
Full name while attending Wofford

Wellness Center:	Counseling:	Disability:
Health Form Immunization records Nurses/MD notes	Consultation notes Treatment notes	Psychological testing Relevant background information Other:

Wellness Center Home

Records Release Form