• Status:
  Freshman
  Transfer
• First Name:
  
• Last Name
  
• Street Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip:
  
• Telephone:
  
• E-mail:
  
• Sex:
  
  • Male
  • Female
• Date of Birth:
  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
• Country of Birth:
  
• Religion:
  
• Marital Status:
  
  • Single
  • Married

Parent or Guardian

• Name:
  
• Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip:
  
• Phone:
  

Family Physician:

• Name:
  
• Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip:
  
• Phone:
  

Father:

• General Health:
  
  • Excellent
  • Good
  • Below Average
  • Poor
• If deceased, give cause:
  

Mother:

• General Health:
  
  • Excellent
  • Good
  • Below Average
  • Poor
• If deceased, give cause:
  

Brothers:

• No. Living:
  
• Health:
  
  • Excellent
  • Good
  • Below Average
  • Poor
• If any deceased, give cause:
  

Sisters:

• No. Living:
  
• Health:
  
  • Excellent
  • Good
  • Below Average
  • Poor
• If any deceased, give cause:
  

Indicate which of your (blood) relatives have had any of the following diseases:

• Cancer:
  
• Tuberculosis:
  
• Nervous Breakdown:
  
• Heart Disease:
  
• Diabetes:
  
• Epilepsy:
  
• Hay Fever:
  
• Comments on Family History:
  

Please indicate immunizations you have received by providing us with dates you received them:

• DPT:
  
• *Tetanus (TD):
  
• *MMR:
  
• *TB Test:
  
• Hepatitis B:
  
• **Chest X-Ray:
  
• Polio:
  
• Other:
  

* Requirements include TD every 10 years, MMR (2 doses), and recent TB test.

** Because of the increased number of cases of tuberculosis world-wide, Hillsdale College requires a TB test or a negative chest x-ray for each of its students prior to admission. An acceptable TB test or chest x-ray is one obtained within the last three years.

• Height:
  
• Weight:
  
• General Health During Childhood:
  
  • Excellent
  • Good
  • Below Average
  • Poor
• Have your ever lived with someone known to have TB?:
  
  • Yes
  • No
  • If so, when?
    
• Check each illness that you have had indicating the year:
  • Measles:
    
  • Epilepsy:
    
  • German Measles (rubella):
    
  • Nervous Breakdown:
    
  • Mumps:
    
  • Discharging Ear:
    
  • Scarlet Fever:
    
  • Hay Fever:
    
  • Chickenpox:
    
  • Strep throat:
    
  • Poliomyelitis:
    
  • Infectious Mononucleosis:
    
  • Asthma:
    
  • Bronchitis:
    
  • Rheumatic Fever:
    
  • Hearing Problems:
    
  • Tuberculosis:
    
  • Hepatitis or Jaundice:
    
  • Heart Trouble:
    
  • Hernia:
    
  • Tonsillitis:
    
  • Comments on illnesses checked above:
    
• Name any other illness and give year:
  
• Surgical Operations:
  
  • Tonsillectomy:
    
  • Appendectomy:
    
  • Other:
    
• Please list any injuries, how they occurred, and the year:
  
• Do you have frequent colds?
  
  • Yes
  • No
• Sinus Trouble?
  
  • Yes
  • No
• Do you have a chronic cough?
  
  • Yes
  • No
• Sore Throat?
  
  • Yes
  • No
• Do you smoke?
  
  • Yes
  • No
    • How frequently?
    • Heavy
    • Moderate
    • Little
• Are you subject to headaches?
  
  • Yes
  • No
    • How frequently?
    • Frequently
    • Moderate
    • Sometimes
• Do you wear glasses?
  
  • Yes
  • No
• Date of last eye examination:
  
• Date of last dental examination:
  
• Have you ever "blacked out" or had fainting spells?
  
  • Yes
  • No
• Do you take medication regularly?
  
  • Yes
  • No
• If yes, what medications do you take?
  
• Do you have any menstrual difficulties?
  
  • Yes
  • No
  • If yes, what are the difficulties?
    
• Are you allergic to any drugs, food, etc?
  
  • Yes
  • No
  • If yes, what are the allergies?
    
• Is there anything in your physical or mental or emotional condition to limit your college activities?
  
  • Yes
  • No
  • If yes, please describe the disease or handicap:
    

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.

• Click to agree
• Name:
  
• Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip:
  
• Phone:
  
• Date:
  
• Witness Name:
  

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.

• Insured's Name (parent):
  
• Insured's Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip:
  
• Phone:
  
• Blue Cross/Blue Shield
  • BCBS Group:
    
  • BCBS Contact:
    
  • BCBS Service:
    
  • Other:
    
• Other Insurance
  • Other Insurance Name:
    
  • Other Insurance Address:
    
  • Other Insurance Group Name:
    
  • Other Insurance Group Number:
    
• Place of Business or Employment (Parent):
  
• Place of Business or Employment Address:
  
• City:
  
• State:
  AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
• Zip: