Dear Freshman or Transfer Student:

STUDENT HEALTH FORM
This form is required for all Freshman, Transfer or Re-admitting students. If you are planning to participate in intercollegiate athletics this physical form must be completed by an M.D. or D.O. or it will not be accepted.

HEALTH INSURANCE WAIVER STATEMENT
This form is required by all students at Buena Vista University every year. This form 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
Emergency contact information
Insurance coverage status and subscriber's name, date of birth

Required immunization dates provided

1-Measles/Mumps/Ruebella (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-Tuberculin PPD (Mantoux)
- Required of ALL international students and others that have traveled outside of the U.S. in the past 12 months OR any student that shows symptoms of TB (see health form)
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

*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:

Hepatitis B- series of three
Varicella- If no history of chicken pox

Complete Physical Exam

Signed (by MD or DO if Intercollegiate Athlete ALL others may be done by nurse practitioner or physician's assistant

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. (Please note that the policy being offered does not cover athletics). 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 return the waver by the date indicated on the form. Any inquiries please contact the Business Office at 712.749.2041

HEALTH INSURANCE WAIVER STATEMENT

Signed and dated

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 1st (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 could result in loss of computer network service until required forms are received

Download/view printable forms

Student Health Form 2007-2008
Download (PDF) >>

Health Insurance Wavier Statement 2007-2008
Download (PDF) >>

Parent/Guardian Athletic Form 2007-2008
Download (PDF) >>