• Please fully complete and submit the form below AND upload the following required medical documents for enrollment:

    1) Childhood vaccination records (these must be submitted before a residential student can move into campus housing or before a commuter student can attend class)

    2) COVID-19 Vaccination Card (if you have been vaccinated)

    3) Health Insurance Card

    4) Any other medical records you want to share with our Medical Services Department (this is optional)

     

  • Personal Information

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  • Health Insurance Information

    A copy of the student's health insurance card should be uploaded at the end of this form.
  • Emergency Contact Information

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  • Personal Health History

    The following health history is confidential, does not affect the student's admission status, and may only be shared with other health care professionals on an as needed basis to ensure the student receives required and/or requested treatment and care, as necessary. 
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  • Family Health History

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  • Document Uploads

    Do not forget to upload your documents before submitting this form.
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  • Acknowledgement

  • Please read the statements below:

    A) I have personally supplied and reviewed the information on this form and attest it is true and complete, to the best of my knowledge. I understand the information is strictly confidential and will not be released to anyone without my written consent, or as otherwise permitted by law. If I should be ill, injured, or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from this form to a physician, hospital, or medical professional involved in providing me with emergency treatment and/or medical care.

    B) I hereby authorize any medical treatment for myself that may be advised or recommended by the Director of Medical Services. 

    C) I am aware I may be charged for some health services provided by the University and I may be billed through the University Business Office, if the account is not paid at the time of the visit. I accept personal responsibility for settling the account with the University Business Office and for payment of incurred charges. I am responsible for filing outpatient charges with my insurance. I also acknowledge my responsibility to Mars Hill University is unaffected by the existence of insurance coverage.

     

    CONTINUE BELOW TO SIGN THE ACKNOWLEDGEMENT

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