Fillable Medical Information Release

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Medical Information Release

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The Medical Information Release form is 1 page long and contains:

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Country of origin: US
File type: PDF

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STUDENT INFORMATION
SIGNATURE
Registrar’s Office
Medical Information Release
Previous Name Date of Birth Banner ID Number
First Name MI Last Name
Mailing Address
City State Zip
Home Phone Number Cell Phone Number Work Phone Number
Student Signature Date
August 2017/PR
Please complete this form, sign, date and mail to: Manchester Community College, Registrar’s Office, Great Path, MS #13, P.O. Box 1046, Manchester, CT 06045-1046
or fax this form to 860-512-3221.
MEDICAL INFORMATION
I hereby grant permission to release copies of:
Please send information to:
FOR REGISTRAR OFFICE USE ONLY
Date Sent/Pickup __________ /__________ /__________ Processed by: _______________________________________________
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Medical Information Release

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Completed 25 July 2020

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