Release of Student Information Form


IMPORTANT: The Frostburg State Department of Physician Assistant Studies PA program is required to provide specific student information to the sites in which you will have a clinical experience. The following information may be required by clinical sites:

 Urine Drug Screen

 Tdap Booster

 MMMR

 Varicella

 Hepatitis B

 TB

 Flu Vaccine

 Criminal Background Check

 Professional Liability Insurance

 

RELEASE

I authorize the Department of Physician Assistant Medicine at Frostburg State University to forward my health information from Certifi as described above, to Student Coordinators, Office Managers, and other clinical site employees in connection with my participation in clinical experiences in the PA program.

 

Print Name: ________________________________

 

Signature: _________________________            Date: ____________