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Records Release Form 

Student Name  
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  

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

          

Please check Records to be released/or obtained: 

Wellness Center: Counseling: Disability:
 
        
 
        
 
        

I wish to exclude the release of these items and information pertaining to: 

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.
        

 

Signature of Student:  
(By typing my name I acknowledge that this constitutes an electronic signature.)
Date:   [None] Select a Date Delete the Date 
 
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:

Wofford College Health Services
429 N. Church Street
Spartanburg, SC 29303