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If you do not live with a parent, please indicate the name of your Guardian or Spouse:
Please check with your insurance carrier to be sure coverage is extended to you as a student over the age of 18. Adequate insurance coverage is required. Student health insurance information is available at the Office of Student Affairs.
Please state details of any medical conditions including diagnosis, age, duration, treatment, and outcome. If you have had any serious, chronic medical problems, please ask your physicianor surgeon to forward to Holy Cross College Office of Student Affairs a copy of consultation, reports, notes, labs, and/or letter summarizing your problem, including past and present treatments and recommendations for continuing care.
If you see a specialist, please have your physician provide a description of the condition, treatment, and list of medications and forward it to the Office of Student Affairs.
Indiana State Law (IC20-12-71) requires that postsecondary students provide proof of vaccination against measles, mumps, rubella, tetanus, and diphtheria. Indiana State Law also requires that individuals be provided information, and indicate receipt by signature, on the risks associated with meningococcal disease and the availability and effectiveness of vaccination. Specific majors, classes, and activities may have additional health requirements. Requests for exemptions based on medical or religious reasons must be filed with the Office of Student Affairs.
M.M.R. (Measles, Mumps, Rubella) (Two doses required.)
1. Dose 1 given at age 12-15 months or later
2. Dose 2 given at age 4-6 years or later, and at least one month after first dose
TETANUS-DIPHTHERIA (Primary series with DTaP or DTP and booster with Td in the last 10 years meets requirement.)
1. Have you had the primary series of four doses with DTaP or DTP?
2. Have you had a Tetanus-Diphtheria (Td) booster within the last 10 years?
TUBERCULOSIS SCREENING (Mantoux)
Result: (Record actual mm of induration, transverse diameter; if no induration, write "0"
Interpretation (based on mm of induration as well as risk factors):
Chest x-ray (required if tuberculin skin test is significant) result:
HEPATITIS B (Three doses of vaccine or two doses of adult vaccine in adolescents 11-15 years of age.)
1. Immunization (Hepatitis B)OR2. Immunization (Combined Hepatitis A and B Vaccine)
Please read important information about the Meningococcal disease and vaccine in THIS DOCUMENT.
I hereby state that my answers to all of the questions are accurate to the best of my knowledge. I give consent to release the information of this report to proper medical authorities in the event I require medical care. (If I am under the age of 18 when I begin at HCC, I have consent from my parent or legal guardian for release of information and for required medical care.)