Health Information

Term:
First Name:
Middle Name:
Last Name:
Student Address:
Student City:
Student State:
Date of Birth MM/DD/YYYY:
In Case of Emergency Contact:
Emergency Contact Home or Cell Phone:
Are you allergic to anything?:
Yes No
If yes, please specify and include all medications to which you are allergic:
Do you take any medication regularly?:
Yes No
If yes, please specify:
BY COMPLETING THIS FORM AND ENTERING MY INITIALS BELOW I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS WAIVER AND WARRANT THAT ALL OF THE INFORMATION I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.
Initials: