Student Immunization Record Submission

    Student Information
    Birthdate*
    Birthdate*
    Student Status*
    Student Status*
    Immunization Information
    Are your immunizations up to date?*
    Are your immunizations up to date?*
    Immunization records are required to be on file in the Office of Student Health Services. Do you have your immunization records available to submit with this form?*
    Immunization records are required to be on file in the Office of Student Health Services. Do you have your immunization records available to submit with this form?*
    It is your responsibility to provide immunization records to the Office of Student Health Services before beginning classes. They can be uploaded, mailed to the College, emailed to healthservices@kwc.edu.

    Acknowledgement
    I have reviewed information listed on this form or I acknowledge that there are no changes to my personal information. I understand that by completing this health form, information may be shared with Kentucky Wesleyan College's physicians, nurses, and mental health counselors. Furthermore, I acknowledge that all information supplied on this form is current and correct to the best of my knowledge.
    I have reviewed information listed on this form or I acknowledge that there are no changes to my personal information. I understand that by completing this health form, information may be shared with Kentucky Wesleyan College's physicians, nurses, and mental health counselors. Furthermore, I acknowledge that all information supplied on this form is current and correct to the best of my knowledge.
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    Signature Date
    Signature Date