Appendix G - Student Release of Information Form

Documents for Release: Student Profile and Student Passport

I, ______________________________________________________, 

           Printed Student Name

hereby authorize Elon University Department of Physician Assistant Studies to release the student profile/passport which includes a copy of my immunization records, tuberculosis screening results, criminal background check drug screen results, ACLS, BCLS, basic personal information and photo, to any clinical education facilities affiliated with the program that I may be placed at for clinical rotations. I understand this is necessary so that I am able to participate in patient care activities in clinical settings during assigned clinical rotations. This authorization will remain in effect until I graduate or am no longer enrolled in the Program. 

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Signature of Student

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Date