Medical History

Florida Christian College requires applicants to submit a brief medical history prior to acceptance. Please answer all questions completely. This information will be treated confidentially and used only in the best interest of the student as authorized by college officials. A medical examination is not necessary unless it is later requested by the college. Withholding requested information is considered grounds for immediate dismissal.

Medical Conditions

Student Name
Date of Birth
Social Security #

Please check any of the following conditions that you have now or have had:

Abnormal Blood Pressure
Allergies
Anemia
Excessive Bleeding
Chronic Cough
Emotional Illness
Epilepsy
Eye Trouble
Frequent Headaches

Heart Disease
Hearing Defects
Ulcers
Tendency to Faint
Rheumatic Fever
Diabetes
Psychiatric
Eating Disorder
Other

If you have checked any of the above conditions, please explain and include date of most recent treatment.

Give nature and date of any operations or injuries

List any medications you are taking

List drugs to which you are allergic

List foods to which you are allergic

I certify that I am in good health and physically able to participate in college life except as follows:

I agree to submit to a physical examination at my own expense should the college require it of me:
Signed

Medical Authorization

Local Phone
Home Phone Business Phone

Name of Physician Physician's Phone
Physician's Street Address
City State Zip

Person to be notified in case of serious injury or illness (parent, guardian, or other designated person).
Relationship to Student

Second person to be notified in case party above is unavailable.
Relationship to Student

I am covered by hospitalization insurance.
I am NOT covered by hospitalization insurance.

Insurance Company Policy Number

I understand that FCC's insurance carrier will reimburse me for injuries received during a college sponsored activity only after my own insurance benefits have been exhausted. I also understand that the college coverage does not apply to expenses due to sickness. I hereby give my permission and authorization for any necessary medical treatment to be given the student named on this form while he or she is a student at Florida Christian College and will assume financial responsibility for such treatment. I further agree that an official of the College is empowered to act as agent for the student in the event he or she becomes incapable of making decisions for himself or herself.
If you are under 18, your parent or guardian must enter their name here