INSTRUCTIONS: Complete all items of this health form. Where questions are not applicable, use symbol "N/A."
IMPORTANT: This form must be completed, returned to the College, and determined complete by Health Services before you can register with the Admissions Office. Information supplied will be used as an aid in necessary care while you are a student.
If this student will not be 18 years old by the first day of classes, please contact the admissions department and fill out a hard copy of this form, with parent signature.
Note: Items marked with an asterisk “*” are required.
¹ These are required vaccinations. A student can request exemption from immunizations by completing the Immunization Waiver form and sending or faxing it to the Hillsdale College Health and Wellness Center.
Note: Please send/email/fax an official immunization record to the Health and Wellness Center so there can be a complete student health record.Contact Info: 183 Hillsdale St., Hillsdale, MI 49242Email: firstname.lastname@example.orgPhone: (517) 607-4368Fax: (517) 607-2222
We hereby authorize immunizations and treatments that are deemed necessary while the above-named student is attending Hillsdale College. We also consent to emergency treatment by a licensed physician at an approved medical facility with use of such anesthesia and medical or surgical procedures as may be deemed necessary for care. We understand that in case of a serious illness or accident we will be notified.
Students are required to show proof on insurance coverage at the time of registration. Students should be aware of the types of benefits their insurance affords and should carry a card with the policy number and information.
Primary Insurance Information
Secondary Insurance Information
Parent's Employment Information
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