Raven EMS Education Program Manual
Authorization for Information Release Form

Student’s name:

I authorize a member of Raven Medical, Inc. to release the following information to the authorized persons listed. Yes No
My name.
My address.
My phone number.
My email address.
My student transcript.
My course grades. Specify which course:

List of persons authorized to receive above information:

Name Agency or Relation

Note: This authorization expires one year after the date below.

Student signature:

Change Log (5.93.000.AIRF)

DateAuthorDescription of ChangeCitations
2023-12-13Becker, T.Theron Jack BeckerCreated this form.
2024-05-17Becker, T.Theron Jack BeckerMoved this form from appendix to student manual.
2024-05-31Becker, T.Theron Jack BeckerAdded content.(Becker, 2023)Becker, T. (2023). CMH education manual. OzarksEMS. https://ozarksems.com/edman.php
2024-08-01Becker, T.Theron Jack BeckerEach form previously had dedicated sub-section numbers, but they were removed for brevity and as none of the other forms are specifically numbered. 5.93.200 was the Authorization for Info Release.
2025-01-08Becker, T.Theron Jack BeckerMoved online from Adobe InDesign document.
Relevant. Resolute. Ready.
Raven EMS Education Manual - Table of Contents
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