Professor having a discussion in class

Records Release Form 

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

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 
429 N. Church Street
Spartanburg, SC 29303