This form must be completed by all students before the beginning of classes. If you do not complete this form, you will not be allowed to sit for classes.
Please note: to complete this form, it is advised to have a copy of your immunization record AND proof of health insurance available to upload.
If you have any questions regarding this form or the information requested, please contact Terri Petzold, Director of Counseling Services, at (270) 852-3183 or firstname.lastname@example.org. All information contained in this form is confidential as defined by HIPAA regulations.