Student Name  

Date of Birth  

Email  

Wofford ID  

Cell phone number  

Are you a current student? Yes
No  

Starting year at Wofford or graduation year if you have already graduated  

Full name while attending Wofford  

I authorize the Counseling Center to: release to
obtain from
exchange information with  

Please include the name, address, and phone number if you are requesting information be given to an off campus party. If listing a professor or college employee, please include their full name.  

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. This authorization will remain in effect until this request is processed.
This authorization will remain in effect until:  
 
I understand that I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).

Signature  

Wofford College
Counseling & Accessibility Services
Hugh R. Black Building
429 N. Church Street
Spartanburg, SC 29303