Internaonal Student Health Form
To be completed by the student if 21 years or older – otherwise, to be completed by parent or guardian.
Name:
Last (family)
First (given) Middle
Phone Number: Date of Birth: (mm/dd/yy)
Permanent Address:
Street/PO Box
City, State, ZIP, Country (if not USA)
Person to be noed in an emergency:
Name
Phone Number
Family Physician:
Name
Phone Number
Address:
Street/PO Box
City, State, ZIP, Country (if not USA)
STUDENT HEALTH HISTORY
Does the student have any serious disorder, such as asthma, ulcers, epilepsy?
Yes
No
If yes, please indicate: ________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Has the student had major surgery (hernia, appendectomy, etc.) within the past six months?
Yes
No
If yes, please indicate: ________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Is the student allergic to any drugs?
Yes
No
If yes, please indicate: ________________________________________________________________________________________
Is the student currently taking prescribed medicine of which the college should be aware?
Yes
No
If yes, please indicate: ________________________________________________________________________________________
Is the student undergoing treatment for any disorder?
Yes
No
If yes, will this treatment be connued while the student is in college?
Yes
No
Does the student have limitaon on parcipaon in physical educaon?
Yes
No
If yes, degree of limitaon: ____________________________________________________________________________________
Does the student have any abnormalies which require special facilies and/or special consideraon?
Yes
No
Has the student any history of mental or emoonal disorders?
Yes
No
REQUIRED IMMUNIZATION
Measles, Mumps, Rubella (MMR)
Laramie County Community College requires each incoming student born on or aer 1/1/57 to be protected
against measles, mumps, and rubella. Compliance with the requirement is in one of three ways, as follows.
Born PRIOR to January 1, 1957
Have ters drawn. If immunity is not indicated by the ters, then you must either start the two-dose series or
have a booster and another MMR ter drawn in six weeks. (aach copy of ters results)
Recipt of 2 MMR vaccinaons REQUIRES SIGNATURE OF MEDICAL PROVIDER (at boom of this page)
MMR #1 _________________ (date) Must be 12-15 months of age or later
MMR #2 _________________ (date) Usually at age 4-6 year old or older, and at least one month aer rst dose
LCCC TB Screening
Tuberculosis evaluaons are required prior to enrolling at LCCC if you:
Were born or lived outside the United States
Traveled outside the United States within twelve (12) months prior to arriving at LCCC.
If you checked either of the above boxes, you are required to obtain a two-step TB skin test and update it annually. Provide
documentaon of the PPD Mantoux Skin Test performed in the US prior to aendance within 48 hours of arrival on campus.
LARAMIE COUNTY COMMUNITY COLLEGE
1400 East College Drive
|
Cheyenne, Wyoming 82007
|
800.522.2993
|
lccc.wy.edu
