Student Medical Information

Student Medical Information

Medical Information provided to on-campus nurse.
First Name
Last Name
Full Name *

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Family Insurance Infomation
Insurance Company*
Policy Number*
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number*

Area CodePhone Number

	Relationship
Heart Disease
Cancer
Diabetes
Epilepsy

	Relationship
High Blood Pressure
Kidney Disease
Emotional Illness
Other

	Date
Measles
Mumps
Rubella
Polio
Tetanus
TB (Tine) Test

	Date
Anorexia
Chicken Pox
Hernia
Malaria
Paralysis
Heart Trouble
Hepatitis
Asthma
Colitis
Mumps
Measles

	Date
Sexually Transmitted Disease
Urinary Tract Infection
High Blood Pressure
Rheumatic Fever
Tuberculosis
Thyroid Goiter
Bulimia
Cancer
Ulcer
Polio

Emergency Contacts
In case of emergency, I wish the following person or alternate to be contacted before any surgical procedure whenever possible.

Recommendation: For first contact, list parents; married students, list spouse. For second contact, list grandparents/adult brother or sister. If these are not an option, list your home pastor.
Primary Contact
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Alternate Contact
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Anything else you would like us to know so that we can best provide for you physically while at ABC?
Will you be at ABC for athletic preseason or student orientation before your 18th birthday?

NoYes
In the event of an emergency:*

I give my permissionI do NOT give my permission
for the college nurse, or other responsible officials of Appalachian Bible College, to act, or give authorization in my behalf, to a physician or licensed paramedic, to take whatever emergency measures necessary for my well-being during my enrollment at ABC.
My signature authorizes Appalachian Bible College officials to obtain medical treatment and procedures for the student named below as may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate health care providers.

My signature additionally authorizes Appalachian Bible College officials to obtain routine medical treatment from appropriate health care providers if symptoms of illness occur (i.e., fever, coughing, unusual rashes, etc.).

This grant of temporary authority shall begin upon arrival on campus and shall remain effective until terminated by the undersigned or upon the 18th birthday of the student.
Applicant's Full Name*

First NameLast Name
Applicant's Date of Birth*

MonthDayYear
Parent's Full Name*

First NameLast Name
Parent's Date of Birth*

MonthDayYear
Should be Empty:

Student Medical Information

Family Insurance Infomation

Family Medical History

Personal Medical History

Present Health Status

Emergency Contacts

Primary Contact

Alternate Contact