GM PROFESSIONAL DEVELOPMENT ASSIGNMENT PROGRAM

							                                          Kettering University
                              1700 West Third Avenue, Flint, MI 48504-4898

* Required: Must be returned before the first day of classes
Note: The following information is confidential for use of the Wellness Center. It will not be released to
anyone without your knowledge or written consent. This form must be properly completed and signed
before student may receive medical care at Kettering University Wellness Center.

Kettering ID # ________________________                  Section A________        Section B_________

Name_________________________________                    Birthdate______________________________
      Last  First Middle                                                Month Day    Year
                                                         Email ________________________________
Address ______________________________                   Phone (    )___________________________
          Street                                            Area Code
       ________________________________                  Cell _________________________________
       City State Zip Code

Name of Legal Guardian (If under 21) or Name of Emergency Notification
____________________________ ___________________
Last Name / First / Middle
________________________________________________
Address       Street
________________________________________________
City / State/Country / Zip Code
(   )___________________________           _______________________________________
Phone (Area Code)                                  Email

INSURANCE INFORMATION:                           IMMUNIZATION HISTORY: MANDATORY

Name of Insurance Company                                                        Month        Year
_______________________________                  *Trivalent Oral Polio (TVOP) ____________________
                                                 *Tetanus (Within past 10 yrs.) __________________
Copy in ENGLISH of coverage                      *MMR _____________________________________

Policy Holder Name:                              Hepatitis B Series       ________________________
______________________________                   (also recommended)
Policy Holder SS#:
______________________________

Group/Policy # __________________                SCREENING TEST: Mandatory, within past 3 years

* If possible please enclose copy of             *TB test:        Date____________ Type__________
  insurance card
                                                 Results_____________________________________
* Please notify the Wellness Center if
  your insurance coverage changes                Chest X-Ray: (If TB pos.)  Date _____________
                                                 Results_____________________________________
FAMILY PHYSICIAN:
                                                 Do You have a chronic illness?
                                                 Yes______No________________________________
                                                 If Yes, explain
Last Name / First / Middle                       ___________________________________________
                                                 ___________________________________________
_______________________________
Street Address / City / State / Zip
                                                 Physical completed or copy of immunization card.
(_______)_______________________
Phone (Area Code)                                Physician Signature:__________________________
Personal Health History: Mark below those health problems you have now or ever had.


Allergies (Drugs):

Other Allergies:           ____________________________________


Asthma, Wheezing      ____________________________________
Bronchitis, Pneumonia ____________________________________

Stomach/duodenal ulcer ___________________________________

Mononucleosis (Mono) _____________________________________

Chicken Pox    Measles       Mumps
______         ______        ______

Do you wear contact lens ___ glasses ___?
Last Eye exam:
                                                             Hospitalizations/Surgeries:
                                                             _________________________
                                                             _________________________
                                                             _________________________
                                                             Medications Taken Regularly:
                                                             _________________________
                                                             _________________________
                                                             _________________________

                                                             Any other Health Problems:
                                                             _________________________
                                                             _________________________
                                                             _________________________



I hereby give my consent to be treated by the                Parent or Guardian
Kettering University Wellness Center staff.                  I hereby give my permission for such
(sign in ink)                                                necessary and emergency care to be
                                                             give my son/daughter at an approved
__________________________________                           medical facility (to be signed in INK by
      Students Signature                                     parent or guardian for all applicants
__________________________________                           under 18 years of age).
             Date

STUDENT:           Please sign and return to:                ______________________________
                   Kettering Univ. International Office                   Parent or Guardian
                   1700 W.Third Ave                          ______________________________
                   Flint, MI 48504-4898                                   Date