ࡱ> *,)_  bjbjuu 80b0b H$@[[[ [[[[ fy@[0H[[[oD[HB ^: AUTHORIZATION FOR RELEASE OF STUDENT HEALTH INFORMATION To: 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, . Please fax my physical to the NROTC Unit, 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 NormalTimothy 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