Submit completed form to Student Health Services, 145 F Sargeant Student Center, 2900 University Avenue, Crookston, MN 56716.
Fax to 218-281-8588 or email Stacey Grunewald (sgrunewa@crk.umn.edu). For questions, contact Health Services at 218-281-8512.
Name ________________________________________________________________ Student ID No. __________________
PRINT (LAST) (FIRST) (Middle) (Maiden or Former Name)
Gender: M F Other: ___________________________________ Date of Birth ________/________/_______
Month Day Year
Home Address _______________________________________________________________________________________
(Number and Street) (City) (State) (Zip Code)
Emergency Contact: Name: ______________________________________________ Phone: ______________________
Indicate your first semester at UMC: S F
Year:__________
PERSONAL HEALTH HISTORY: Comment on all positive answers in the space below
HAVE YOU HAD?
YES
NO
HAVE YOU HAD?
YES
NO
HAVE YOU HAD?
YES
NO
Diabetes
Tuberculosis
FEMALES ONLY
Epilepsy
Asthma
Irregular Periods
Sinusitis
Gastrointestinal problems
Severe Cramps
Ear, Nose, Throat Problems
Back problems
Excessive Flow
Head Injury with Unconsciousness
Bone, joint, or muscle problems
ALLERGIES
Insomnia
Tumor, Cancer or Cyst
Penicillin
Frequent Anxiety
Eating Disorder
Sulfa
Depression
Skin issues (acne, eczema, etc.)
Amoxicillin
Worry or Nervousness
Dizziness, Fainting
Other
Comments:
practitioners in the past 3 years? (other than routine checkups).
problem?
I hearby state that the above information is true and accurate.
Stud
ent Signature:__________________________________________________ Date:___________________________
OFFICE USE ONLY: PeopleSoft Date __________
Medical History
To the Student:
Information you provide
will be used to provide
necessary health care.
click to sign
signature
click to edit
Student Immunization Record
Minnesota Law (M.S. 135A. 14) requires that all students born after 1956 and enrolled in a public or private postsecondary school in Minnesota be immunized
against diphtheria, tetanus, measles, mumps, and rubella, allowing for certain specified exemptions (see below). This form is designed to provide the school
with the information required by the law and will be available for review by the Minnesota Department of Health and the local community health board.
WARNING: To avoid registration delays, this form MUST BE COMPLETED and received by UMC Health Services.
Part 1 : Minnesota High School or Age Exemption
Students who graduated from a Minnesota High School after January 1997 or were born before 1957 do NOT need to complete Part 2, 3, or 4.
I graduated from a MN High School after January 1997. High School _____________________________________________ Graduation Year___________
Student Signature Date
Part 3 : Medical Exemption
Students wishing to file an exemption to any or all of the required immunization must complete the following:
The student named above does not have one or more of the required immunizations because they have (check all that apply):
a medical problem that precludes the ______________________________________________________ vaccine(s)
not been immunized because history of _____________________________________________________disease
laboratory evidence of immunity against ________________________________________________________________
Physician’s signature ________________________________________________________________________________ Date_______________________
Conscientious exemption: I hereby certify by notarization that immunization against _______________________________is contrary to my conscientiously
held beliefs.
Student Signature Date
Subscribed and sworn before me on the __________day of ___________________, 20_____.
Signature of notary __________________________________________________________________________________________
Disability Resource Center : Optional Section, but strongly encouraged
Information in this section will be shared with UMC’s Disability Resource Center. Students who complete this section will receive additional information from the
Disability Resource Center.
Do you have a medical or educational related disability that may have an impact on your academic program? If yes, please specify;
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Parental Consent - The law requires that a parent/guardian grant permission for medical evaluation and/or treatment of minors (any student under 18 years of age).
The following consent must be signed by a parent/guardian of a minor so that he/she may receive medical evaluation/treatment. No major medical or surgical procedure
will be performed, except in an emergency, without the parent/guardian first being contacted.
Authorization: The undersigned parent/guardian hereby grants permission for the University of Minnesota, Crookston personnel to provide medical evaluation treatment
and/or to obtain emergency treatment for the above-named minor. The undersigned parent/guardian further agrees to pay all expenses of such evaluation and/or treatment.
Name of parent/guardian____________________________________________________ Telephone____________________________________
Signature of parent/guardian_______________________________________________________________ Date_______________________________
Part 2 : Immunizations if you do NOT provide proof of these required immunizations you will need to get the following vaccines.
Diphtheria/Tetanus(Td or Tdap):
Most current, given every 10 years
Month/year:_______/_______
Measles (rubeola, red measles):
2 doses after age 12 month
Month/year of dose 1:________/_______
Month/year of dose 2:_______/_______
Mumps:
2 doses after age 12 months
Month/year of dose 1:_______/________
Month/year of dose 2:_______/_______
Rubella (German Measles):
2 doses after age 12 months
Month/year of dose 1:_______/________
Month/year of dose 2:_______/_______
I certify that the above information is a true and accurate statement of the dates on which I received the immunizations required by Minnesota State Law.
Student Signature Date
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome