Authorization Effective Date: ______________________________
Authorization Expiration Date, if Applicable: ________________
I understand that this authorization permits release only of the information identified above and that the NLU PA Program will limit the release to information necessary for the stated purpose.
Student Signature: ________________________________________
Date Signed: _____________________________________________
SECTION V. ELECTRONIC STUDENT FILE DOCUMENTATION
Date This Form Was Placed Into the Student Electronic NLU PA Program File:
Electronic File/Record Location:
Uploaded/Entered By: _____________________________________
Title/Role: ______________________________________________
Date Uploaded: ___________________________________________
SECTION VI. PROGRAM RECORD VERIFICATION
☐ Student immunization compliance verification completed.
☐ Required health-screening compliance verification completed.
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