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: ____________