Matriculate Class 2011

Health Professional Schools

Applicant Authorization to Release HPAC Letter

I hereby authorize Lafayette’s Health Professions Advisory Committee to send a composite letter of evaluation on my behalf for admission to the following health professional schools. Included are my MCAT/DAT/OAT/GRE scores and the dates as well as my AAMC/AACOMAS/DAT/OAT identification number that will be included in the HPAC composite letter.

Applicant Name
Applicant Signature / Date:
Test Name / Score / AAMC ID #
MCAT #1 / Date: / AMCAS Letter ID#
MCAT #2 / Date: / AACOMAS ID#
DAT #1 / Date: / AADSAS ID#
DAT#2 / Date: / OAT ID#
OAT / Date: / GRE ID#
GRE / Date: / OTHER ID#

I am applying to the following schools:

School Name / School Name
1. / 11.
2. / 12.
3. / 13.
4. / 14.
5. / 15.
6. / 16.
7. / 17.
8. / 18.
9. / 19.
10. / 20.

I hereby waive my right of access (granted under the Family Educational Rights and Privacy Act of 1974) to any part or all of the HPAC composite letter of evaluation (that includes the my identification number, GPA, grades, and rank in class) written on my behalf by the Lafayette Health Professions Advisory Committee, provided that it is used solely with respect to my application for admission to a health professions school or relevant post-baccalaureate programs, or in connection with applications for scholarships or financial aid to fund a health professions education. I understand that the recipient of my records will be informed of my decision regarding this waiver.

Student Signature / Date:

I also understand that Lafayette College will process and send my first 15 applications to health professions schools (including post-baccalaureate programs) at no charge but that for each and every additional school on my designated list I will be assessed a $25 processing fee.

Student Signature / Date: