Last Name   First Name   M.I.
Student ID  
Date of Birth   Entering as a:
Home Address   City   State   ZIP  
Resident Status
Home Phone Cell Phone   Email Address  
Emergency Contact's Name   Relationship
Home Phone   Cell Phone
Home Address  
Alternate Emergency Contact's Name   Relationship
Home Phone   Cell Phone
Personal History (Please answer all questions.)
Health conditions in case of emergency ( List if you had any of these : Diabetes, Hay fever/Asthma, Heart Murmur, Convulsions/Seizures, Head injury, Sickle Cell Trait, Concussion or any others you would like us to know about)(type none if none)
ALLERGIES: Describe known allergies or drug sensitivities (type none if none)  
MEDICATION: Prescription, over the counter, supplements you are taking (type none if none)
Physical Examination complete
NOTE: If you have completed the Physical Exam, please submit the completed form to your head coach. This is required for the Athletes.
I have medical insurance:   
Provider Policy #
NOTE: Your medical insurance must provide athletic accident / injury coverage outside your state of residence. If you do not have personal medical insurance that covers athletic accidents / injuries you will be required to carry a primary accident insurance policy. Please contact: for further information.
All US student-athletes are encouraged to turn in a copy of their immunization records to the Health Services Office. International student-athletes are required to turn a copy of these records to the Health Services Office.
A copy of any updates to your immunization record, occuring while you are attending BCU, should also be provided to the Health Services Office.
Meningococcal Meningitis Vaccine - Should be considered, especially for freshman living in the residence halls. Meningitis potentially can be fatal or leave devastating side effects, such as hearing loss, renal failure, brain damage or even limb damage requiring amputation. This disease can be vaccine preventable for some strains of meningitis. For more information, visit the National Meningitis Association website at
STATE LAW REQUIRES the following information be submitted for new students living in the residence halls.
Meningococcal immunization    Date Received
Briar Cliff University has provided me information explaining the risks of meningococcal disease
Health Information Release Consents
A consent is required prior to the release of any health information.
I hereby authorize Briar Cliff University to release either verbally or by documentation, the data from my the medical record:
 Briar Cliff University Athletic Department
 My parents and/or guardian (Enter Names)
I understand that I may withdraw this consent at any time by providing written notice.
Student Agreement   DATE
Age of student:
Parent's Consent for Student Under 18 Years of Age
In case of an accident or emergency where there is not time to contact the parents/guardian, I hereby give the university authority to make decisions for treatment or surgery for my son/daughter.
I hereby certify that the information above is true and accurate.
Parent(s) or Guardian(s) Name:
Parent or Guardian Agreement
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