ࡱ> *,)_  bjbjuu 80b0b H$@[[[ [[[[ fy@[0H[[[oD[HB ^: AUTHORIZATION FOR RELEASE OF STUDENT HEALTH INFORMATION To: College of the 51СƳ Health Services Worcester Polytechnic Institute Health Center Worcester State University Health Services Brown University Health Services I, _______________________________, hereby authorize release of my Medical Record Form/ Health Examination Report from my university health services record to the Department of Naval Science, College of the 51СƳ. Please fax my physical to the NROTC Unit, College of the 51СƳ at (508) 793-2373. __________________________________________ (Signature/Date) __________________________________________ (SSN or School ID Number) __________________________________________ (College Class) %,78:;<Zk 4 ? @ h   T d e  ᭴ haha ha5 hEha hEhE hS,lh~mh~mhEhS,l hS,lhahahah}c5 hE5 h5haha5&89:l   N e f 7$8$H$gdE gdS,l`gdS,l:$$d%d&d'd(d)fNOPQRSa$gd  6&P1h:pS,l/ N!"# $% s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<    8@0(  B S  ?%,8899::;<Zkll#MT%,8899::;<Zkll cg  LaOd-S,l\r}c~mE@@UnknownG.[x Times New Roman5Symbol3. .[x ArialA$BCambria Math"hhh׆rr! xr43HP ?d-2!xxCEZ /AUTORIZATION FOR RELEASE OF STUDENT INFORMATION Holy Cross Timothy Wrenn Oh+'0  8D d p | 0AUTORIZATION FOR RELEASE OF STUDENT INFORMATION 51СƳNormalTimothy Wrenn2Microsoft Office Word@@ @x@@x@r ՜.+,0 hp|   0AUTORIZATION FOR RELEASE OF STUDENT INFORMATION Title  "#$%&'(+Root Entry FBiy@-1Table WordDocument8SummaryInformation(DocumentSummaryInformation8!CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q