Student Health Form


Your Name:  

Your Student ID Number:  

 Are you a returning student?    

If you are a returning student with no changes to any part of your required information, all you need to do is skip to the bottom of this document, acknowledge the meningitis vaccination disclosure, and sign the document. If you are a new student or a returning student with changes to some part(s) of your required information, please review the information below, then acknowledge and sign the document.

 

Demographic Information

If you are a returning student with no changes to your demographic information, this section will be blank; otherwise, please review the information below.

Your Home Address:

 

Your Home Phone Number:  

Your Cell Phone Number:  

Your Birth Date:  

Your Social Security Number:  

Your Gender:       Your Race:      Your Marital Status:  

Emergency Contact Name:  

Emergency Contact Address:

   

 

Health Information

Your Height:     Your Weight:  

 

These are the medications that you indicated are taken regularly

 

These are the medications that you indicated are known allergies

 

These are your known medical issues                 These are the details you supplied about the issue(s)

 

 

Are your immunizations current?  

 

 

   I have verified the uploaded copy of my primary Health Insurance Card is correct and legible.

 

Meningitis Vaccination Information

Pursuant to Kentucky Legislature House Bill 342 that became effective July 1, 2004, Kentucky educational institutions of higher learning that provide residential housing are required to provide information regarding meningitis to full-time students living in residential housing.

Bacterial meningitis is a rare but potentially fatal disease. It is caused by a bacterial infection that may cause severe inflammation of the brain and spinal cord. Adverse side effects might include brain damage, hearing loss and/or loss of limbs. 

College students who live in dormitories are at a slightly increased risk for contracting meningococcal disease than the general population.

 

Should you be interested in the vaccine, please see your primary care provider.

I have reviewed any new or changed information listed on this form or I acknowledge that there are no changes to my personal information. Furthermore, I acknowledge that all information supplied on this form is current and correct to the best of my knowledge.

 

 

 

 

Leave this empty:

Kentucky Wesleyan College https://kwc.edu
Signature Certificate
Document name: Student Health Form
Unique Document ID: 157af821720dae0b307295f1a304c140ff45d70e
Timestamp Audit
May 8, 2018 9:08 am CDTStudent Health Form Uploaded by C Bryan Blount - [email protected] IP 24.106.144.66
May 10, 2018 10:38 am CDTTonya Marksberry - [email protected] added by C Bryan Blount - [email protected] as a CC'd Recipient Ip: 24.106.144.66
May 10, 2018 11:06 am CDTTonya Marksberry - [email protected] added by C Bryan Blount - [email protected] as a CC'd Recipient Ip: 24.106.144.66
May 14, 2018 9:41 am CDTTonya Marksberry - [email protected] added by C Bryan Blount - [email protected] as a CC'd Recipient Ip: 24.106.144.66
May 14, 2018 9:51 am CDTTonya Marksberry - [email protected] added by C Bryan Blount - bb[email protected] as a CC'd Recipient Ip: 24.106.144.66
May 16, 2018 7:47 am CDTTonya Marksberry - [email protected] added by C Bryan Blount - [email protected] as a CC'd Recipient Ip: 24.106.144.66