Graceland University Health Form

To the Student: If there is any health problem or handicap, it is recommended that you request your physician to forward any information to Student Health Services which will be of assistance in providing care. This information is strictly for the use of Student Health Services and athletic trainers if you are an athlete. Any other information held within your Health Service file is strictly for the use of Student Health Services. No health information will be released to anyone without your knowledge and written consent.

You must fax a copy of both sides of your insurance card to Student Health Services at 641-784-5487.
 
  CONTACT INFORMATION *Required
 
*Student ID:  
*Student First Name:  
Student Middle Name:  
*Student Last Name:  
*Gender:  
Male Female
*Date of Birth:  
  (mm/dd/yyyy)
 
*Home Address:  
Address 2:  
*City:  
*State/Province:  
*Zip/Postal Code:  
*Country:  
 
*Home Phone:  
Cell Phone:  
Mother's Name:  
Mother's Cell Phone:  
Father's Name:  
Father's Cell Phone:  
 
*Emergency Nofity First Name:  
*Relationship to Student:  
*Home Phone:  
Cell Phone:  
 
  MEDICAL INFORMATION
 
  INSURANCE INFORMATION