Last Name*   First Name*   M.I.
Student ID*   Gender*  
Date of Birth*   Entering as a:
Home Address*   City*   State*   ZIP*  
Resident Status
Home Phone Cell Phone*   Email Address*  
 
EMERGENCY CONTACT INFORMATION
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/Concussion, Sickle Cell Trait or any others you would like us to know about)(type none if none) *
 
ALLERGIES: Describe known allergies and/or drug sensitivities (eg. Food, Seasonal, Insect allergies) (type none if none)*  
MEDICATION: Prescription, over the counter, supplements you are taking (type none if none)*  
Physical Examination complete*
NOTE: This is only required for the Student Athletes. If you have completed the Physical Exam, please submit the completed form to your head coach.
INSURANCE INFORMATION
I have medical insurance*:   
Provider*   Policy # *
IMMUNIZATION INFORMATION
All student-athletes are encouraged to turn in a copy of their immunization 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 www.nmaus.org.
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 Consent
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 medical record to:
 Briar Cliff University Health Services/Outside Health Care Providers
 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
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  
Click to Print This Page
Submit
Copyright 2012 by Briar Cliff University