Required Forms

Student Health Form - 2014-2015
Download (PDF)

International Student Health Form - 2014-2015
Download (PDF)

Parent/Guardian Athletic Form 2014-2015
Download (PDF)

Sickle Cell Disclosure Form 2014-2015
Download (DOCX)

Dear Freshman or Transfer Student:

  • STUDENT HEALTH FORM
    This form is required for all Freshman, Transfer or Re-admitting students.
  • HEALTH INSURANCE WAIVER STATEMENT
    This waiver statement is required by all students at Buena Vista University every year. This statement indicates states that you have your own health insurance and DO NOT want to be automatically enrolled in the Student Health Insurance Plan offered by Buena Vista University.
  • PARENT/GUARDIAN/STUDENT INFORMATION FORM (Intercollegiate Athletes only) This form provides the Athletic department with primary insurance coverage information and MUST be filled out completely.

Review this checklist before mailing:

STUDENT HEALTH FORM  (completed)

All subjective information is completed on front page including:

  • Medication allergies
  • Phone numbers including cell phone numbers
  • Emergency contact information
  • Insurance coverage status and subscriber's name, date of birth

Required immunization dates provided

    1. Measles/Mumps/Rubella (MMR)
      • Dose #1 15 months or after
      • Dose #2 age 4-5 years or after
    2. Tetanus/Diphtheria
      • Primary series-date completed
      • Booster within the past 10 years
    3. Polio (OPV)
      • Primary series-date completed
    4. Meningococcal Vaccine
      • One dose required to reduce the risk for potentially fatal bacterial meningitis
      • Menactra-provides coverage for up to 7 years (recommended)
      • Menomune-provides coverage for up to 3 years
    5. Tuberculin PPD (Mantoux)
      • Tuberculosis (TB) Screening Assessment (To be completed before your physician’s appointment)

      *Students wishing to file an exemption to any or all of the required immunizations must obtain medical exemption from a health care provider.

Recommended but not required:

  1. Hepatitis B- series of three
  2. Hepatitis A - series of two
  3. HPV (Human Papillomavirus) - series of three
  4. Varicella- If no history of chicken pox

Complete Physical Exam

        • Signed by MD or DO, ARNP, or PA 

Emergency Treatment Consent

        • Signed and dated

Required Health Insurance

        • All full-time students (12 credit hours or more) and/or students residing on campus are required to have health insurance. If you have health insurance coverage and do not wish to be enrolled in the policy offered by Buena Vista University, complete the waiver form. The cost of the policy offered by BVU will be added to the student's registration fees if the parent/guardian or the student does not complete the on-line waiver by the date indicated on the form. Any inquiries please contact the Business Office at 712.749.2041

HEALTH INSURANCE WAIVER STATEMENT

        • Completed on-line

COPY OF CURRENT HEALTH & PHARMACY CARDS
Name of subscriber and date-of-birth provided (subscriber is whoever carries the insurance through work or privately)

PARENT/GAURDIAN/STUDENT INFORMATION FORM (completed)
Intercollegiate athletes ONLY

Return ALL forms to HEALTH SERVICES by AUGUST 1 (do not send other contracts).

Buena Vista University
610 West Fourth Street
Forum Box 2025
Storm Lake, Iowa 50588
Tel: 712.749.1238
Fax: 712.749.1467

      • Forms must be received before you are allowed to finish the validation process
      • Failure to comply with deadline will result in an academic hold on your account until required forms are received.