Butler Community College Resident Information & Health Form
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Student’s Full Name Date of Birth Social Security Number or BCC I.D.
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Student’s Cell Phone Number Student’s Home Phone Number
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Name of Parent(s) or Guardians Best Number to Reach Parent/Guardian
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Additional Emergency Contact Name & Phone Number
General Information
Current Medical Conditions or Medications taken regularly: _____________________________
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Have you ever been hospitalized? (For what, when and why): __________________________
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Allergies: ___________________________________________________________________________
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Medical Insurance Information
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Current Insurance Information (Name & Policy Number)
In case of emergency, I hereby give my consent to receive first aid treatment, and release
my medical records to caregivers.
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Signature of Student Date Signed
