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Health Form

» Admission & Aid » Traditional Admission » Admitted Students » Health Form

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Traditional Admission
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About Huntingdon College
Learn More
Traditional Admission
- Freshman
- Transfer
- Other
Admitted Students
Student Financial Services

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 Health Services at (334) 833-4440.

Student Health Form

Name of person completing this form * Required
First Last
The person completing this form is * Required
- The student (must be age 19 or older)
- The student's parent or guardian (if student is under age 19)
Student's date of birth * Required
MM slash DD slash YYYY

mm/dd/yyyy
Date you are completing this form * Required
MM slash DD slash YYYY
Student's age as of this date * Required

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 last name * Required
Student's first name * Required
Student's middle name
Student's preferred name/nickname
Student's home (permanent) address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Student's cell phone * Required
Student's Email * Required
Student's gender * Required
- Male
- Female
Emergency contact * Required
Emergency contact's relationship to student * Required
Emergency contact's phone * Required
Medical Documentation
Please upload the student's immunization record here.
Max. file size: 300 MB.
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.
If the student was born after 1957, he/she is required to have had two doses of the MEASLES, MUMPS & RUBELLA vaccine, with the last dose administered since 1980. In the space provided, please list the dates of the student's MMR vaccinations. * Required
Was the student's first dose?
- ME
- MR
- MMR
Was your student's second dose?
- ME
- MR
- MMR
Please provide the full name and phone number of the student's physician: * Required
If the student has received the Meningococcal Meningitis vaccine, please give the date below.
If the student has received the Hepatitis B Series, please give the date of the series.
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
- Yes
- No
If the student was born in one of the countries listed above under the Tuberculosis Questionnaire header, please state the country: * 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
- Yes
- No
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
- Yes
- No
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
- Yes
- No
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
- Yes
- No
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
- I understand and will download the form and print it for completion by my health care provider.
- I understand; no form is necessary because I did not answer YES to any of the required TB questions.
Medical History
Please list medication/food/insect allergies:
Please list current medications, including dosages:
Has the student ever received psychiatric treatment?
Please list/describe any serious injuries or surgeries, with dates:
Please select if the student has or has had any of the following: * Required
To choose more than one, hold down the Control key on your keyboard.
If you selected "other" above, please describe:
Please list any parent, sibling or grandparent significant illnesses (see list above), attributing the health concern to the patient's relationship to the student.
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.
Name of Medical Insurance provider:
Policy holder's name:
Policy holder's date of birth, including year:
Policy number:
Group number:
Please attach a copy of the front and back of your health insurance card.
Max. file size: 300 MB.
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.
- Agree
Student: please sign this form by writing your name.
First Last
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.
- Agree
Parent/Guardian: Please sign this form by writing your name.
First Last

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Huntingdon College is a college of the United Methodist Church.

Huntingdon College is committed to a policy against legally impermissible, arbitrary, or unreasonable discriminatory practices. Therefore, Huntingdon College, in accordance with Title IX and Section 106.8 of the 2020 Final Rule under Title IX of the Education Amendments of 1972, other applicable federal and state law, and stated College policy, prohibits discrimination on the basis of sex. Furthermore, Huntingdon College, in accordance with applicable federal and state law and stated College policy, prohibits discrimination on the basis of actual or perceived gender, gender identity, race, color, ethnicity, sexual orientation, disability, religion, age and/or national origin in its education program or activity, including admission and employment.

Huntingdon College also prohibits retaliation against any person opposing discrimination or participating in any discrimination investigation or complaint process internal or external to the institution. Sexual harassment, sexual assault, dating and domestic violence, and stalking are forms of sex discrimination, which are prohibited under Title IX by policy.

Any person may report discrimination (whether or not the person reporting is the person alleged to have experienced the conduct), and may do so in person, by mail, by telephone or by email using the contact information below.

Inquiries and/or complaints that are not related to disability discrimination can be addressed to:
Huntingdon College Title IX Coordinator
Eric A. Kidwell
Library
1500 East Fairview Ave.
Montgomery, AL 36106
TitleIXCoordinator@hawks.huntingdon.edu
334-833-4420* (This number is for discrimination-based reporting.)
Huntingdon’s full policy and process, including an online reporting form, may be found at: https://www.huntingdon.edu/misconduct

Inquiries and/or complaints may also be addressed to (though it is advised the College’s process be first utilized):
Assistant Secretary
Office for Civil Rights (OCR)
U.S. Department of Education
400 Maryland Avenue, SW
Washington, D.C. 20202-1100
Customer Service Hotline #: (800) 421-3481
Facsimile: (202) 453-6012
TDD#: (877) 521-2172
Email: OCR@ed.gov
Web: http://www.ed.gov/ocr

Access Services
Within any resolution process related to this policy, Huntingdon College provides reasonable accommodations to persons with disabilities when that accommodation is consistent with federal law. For disability-related inquiries or complaints:
Huntingdon College Director of Access Services/ 504 Coordinator
Dr. Lisa O. Dorman
1500 East Fairview Ave.
Montgomery, AL 36106
ldorman@hawks.huntingdon.edu
334-833-4465 (This number is for requesting disability accommodations.)

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