Housing Medical Information Form - Fort Scott Community College

FSCC Housing Medical Information Form

Name(Required)

First Last

Sex(Required)

Male

Female

FSCC Sport or Program(Required)

Address(Required)

City State / Province / Region ZIP / Postal Code Country

Medical Conditions staff should be aware of

Medications

Allergic reactions to

IN CASE OF EMERGENCY CONTACT:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

MUMPS & MEASLES

Have you had at least one MMR vaccination(Required)

Yes

Have you had the measles?(Required)

Yes

MENINGITIS

FSCC recommends that all students living in FSCC housing have a meningitis vaccination. Before a student can move into housing, he/she must provide a copy of his/her meningitis vaccination record or sign the waiver below.

Have you had a meningitis vaccination?(Required)

Yes

If YES, a copy of your meningitis vaccination record must be on file with FSCC. If NO, read and sign the following.

Student Signature(Required)

Parent/Guardian Signature (unless over 17)

Today's Date(Required)

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