E Cedarville University Student Health Form printable pdf download

Student Health Form (Page 1 of 6)

All undergraduate campus-based students are required to complete the Cedarville University Student Health Form and return it by August 1 for fall semester, or January 1 for spring semester. Physical and dental exams

are not required but strongly recommended. However, proof of measles immunity (rubeola) is required. As with all medical information, the confidentiality of your records will be maintained. Please see University Medical

Services (UMS) Notice of Privacy Practices posted online at cedarville.edu/privacypractices. If you have any questions about this form, please call UMS at 937-766-7862 or email us at

ums@cedarville.edu.

SectIon 1: DeMogrAphIc InforMAtIon

________________________________________________________________________________________________________________________________

Student’s Last Name (please print)

First Name

Middle Name

________________________________________________________________________________________________________________________________

Social Security Number

Date of Birth (month/day/year)

________________________________________________________________________________________________________________________________

Home Address (number and street)

City

State

Zip

Country

________________________________________________________________________________________________________________________________

Cedarville University Student ID Number

Home Phone Number

Cell Phone Number

Sex q M

q F

Marital Status q Single q Married q Divorced q Widowed

________________________________________________________________________________________________________________________________

Person to Contact in Case of Emergency

Relationship (parent, guardian, spouse)

________________________________________________________________________________________________________________________________

Contact’s Address

________________________________________________________________________________________________________________________________

Contact’s Phone Number

SectIon 2: StAteMentS of AUthorIzAtIon

1. I authorize and request UMS to administer outpatient and inpatient care, including medical and surgical services, immunization, and emergency procedures as necessary, or to defer to duly licensed medical personnel when

indicated, including transfer to hospitals.

I hereby state that I am capable of safely participating in vigorous physical activity offered through physical education, intramural, and intercollegiate athletics, unless otherwise noted in this Cedarville University Student

Health Form.

________________________________________________________________________________________________________________________________

Signature of Student

Date

________________________________________________________________________________________________________________________________

Signature of Parent or Guardian (if student is under age 18)

Date

2. I hereby acknowledge that I have been notified that a copy of the UMS Notice of Privacy Practices is available at the following web site: cedarville.edu/privacypractices.

I am aware that UMS has included a provision that states it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.

I understand that if I should have any questions about the UMS Notice of Privacy Practices, I can call UMS at 937-766-7862.

________________________________________________________________________________________________________________________________

Signature of Student

Date

________________________________________________________________________________________________________________________________

Signature of Parent or Guardian (if student is under age 18)

Date

University Medical Services • 251 N. Main St. • Cedarville, OH 45314 • 937-766-7862 • fax: 937-766-7865 • ums@cedarville.edu • cedarville.edu/ums