Take Note

A Service of Lessons and Carols

Thurs., Nov. 30, 7:00 p.m., Ligon Chapel; free and open to the public

Health Form

New students who are age 19 or older must complete this form; students who are younger than 19 must have this form completed by a parent or guardian.

Information shared on this form will be kept confidential and will be shared with appropriate College personnel on a need-to-know basis only.

The following documents are necessary to complete this form:
  • Student’s immunization record (copy uploaded to computer)
  • A list of surgeries and significant illnesses
  • A list of the student’s medications
  • Health insurance card (copy front and back uploaded to computer)

If you require assistance with completion of this form or if you have any questions, please contact the Office of Student Affairs at (334) 833-4407.

Student Health Form

  • Name of person completing this form * Required
  • The person completing this form is * Required
  • mm/dd/yyyy
  • NOTE: If the student is younger than age 19, this form must be completed by the student's parent or guardian
  • Student Information

  • Student's home (permanent) address * Required
  • Student's gender * Required
  • Medical Documentation

  • To upload the student's immunization record, obtain the record from the student's physician, scan and save it to your hard drive, then select the file to upload it to the website. If you are unable to complete this process, you may send the original immunization record to the Huntingdon College Office of Admission, 1500 E. Fairview Ave., Montgomery, AL 36106.
  • Was the student's first dose?
  • Was your student's second dose?
  • Tuberculosis Questionnaire

    Some of the questions below pertain to the following countries, which have a high prevalence of TB disease: Afghanistan, Algeria, Angola, Argentina, Armenia, Azerbaijan, Bahrain, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia (Plurinational State of), Bosnia and Herzegovina, Botswana, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Burundi, Cabo Verde, Cambodia, Cameroon, Central African Republic, Chad, China, Colombia, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Dominican Republic, Ecuador, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Fiji, Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran (Islamic Republic of), Iraq, Kazakhstan, Kenya, Kiribati, Kuwait, Kyrgyzstan, Lao People's Democratic Republic, Latvia, Lesotho, Liberia, Libya, Lithuania, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia (Federated States of), Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nauru, Nepal, Nicaragua, Niger, Nigeria, Niue, Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Qatar, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, Saint Vincent and the Grenadines, Sao Tome and Principe, Senegal, Serbia, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, South Sudan, Sri Lanka, Sudan, Suriname, Swaziland, Tajikistan, Thailand, Timor-Leste, Togo, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Tuvalu, Uganda, Ukraine, United Republic of Tanzania, Uruguay, Uzbekistan, Vanuatu, Venezuela (Bolivarian Republic of), Viet Nam, Yemen, Zambia, or Zimbabwe.
  • Has the student ever had close contact with persons known or suspected to have active TB disease? * Required
  • Has the student had frequent or prolonged visits (the significance of the travel exposure should be discussed with a health care provider and evaluated) to one or more of the countries listed above with a high prevalence of TB disease? * Required
  • Has the student been a resident and/or employee of a high-risk congregate setting, such as a correctional facility, a long-term care facility, or a homeless shelter? * Required
  • Has the student ever volunteered or served as a health care worker with clients who are at an increased risk for active TB disease? * Required
  • Has the student ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease: medically underserved, low-income, or abusing drugs or alcohol? * Required
  • If the answer to any of the questions above in the Tuberculosis Questionnaire section was YES, or if the student was born in one of the countries listed above, Huntingdon College requires that the student receive TB testing as soon as possible but at least prior to the start of the the subsequent semester. If the answer to the above questions was NO, and if the student was not born in one of the countries listed, no further testing or action is required. * Required
  • Medical History

  • To choose more than one, hold down the Control key on your keyboard.
  • Example: grandparent: high blood pressure; sister: congenital heart disease; mother: cancer
  • Health Insurance

    As of January 1, 2014, federal law requires health insurance for every individual. Huntingdon College strongly recommends that every student be covered by health insurance.
  • Signatures

  • IF THIS FORM WAS COMPLETED BY THE STUDENT: I certify that, to the best of my knowledge, this form is complete and current. I understand that I am responsible for my own physical and mental health and for informing staff of my need for treatment. I hereby grant Huntingdon College permission to authorize emergency medical and surgical treatment for me. I understand that the College will make arrangements without assuming financial responsibility. The emergency contact will be notified promptly in the event of a serious accident or illness except where delay by such communication would endanger life.
  • Student: please sign this form by writing your name.
  • IF THIS FORM WAS COMPLETED BY THE STUDENT'S PARENT OR GUARDIAN I certify that, to the best of my knowledge, this form is complete and current. I understand that the student is responsible for his/her own physical and mental health and for informing staff of any need for treatment. I hereby grant Huntingdon College permission to authorize emergency medical and surgical treatment for my son/daughter. Such permission includes referral to a local hospital, which may result in hospitalization, anesthesia, and/or surgery, should it be necessary and I am unable to be contacted. I understand the College will make arrangements without assuming financial responsibility.
  • Parent/Guardian: Please sign this form by writing your name.