Student Name Please enter stundent name

Date of Birth Please enter date of birth

Email This is not a valid email. Please type your email.

Wofford ID Please enter your Wofford ID

Cell phone number Please enter your cell

Are you a current student?

Yes

No

 

Starting year at Wofford or graduation year if you have already graduated Please enter the year you started or graduated Wofford.

Full name while attending Wofford Please enter your full name while attending Wofford.

I authorize the Counseling Center to:

release to

obtain from

exchange information with

Please specify recipient of records.

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. Please specify contact information.

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:

 
Please fill out end authorization date
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 Please fill out e-signature.

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