Student Medical Form | Enrollment Kit

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Student Medical Form | Enrollment Kit

These medical forms are required of all full-time students and must be submitted prior to the start of class.

First Name:

Last Name:

Date of Birth:

Email Address:

Primary Phone Number:

Address:

City:

State:

Zip:

Student Living Arrangement

Proof of Health Insurance

Health Insurance is MANDATORY for all students! Proof of valid health insurance is required prior to the start of classes. If you do not have health insurance or have additional questions about health insurance, learn more on our health insurance page.

Group Insurance Number:

ID Plan Number:

Group Health Insurance Carrier:

File Upload of Insurance Card (Front)
Please submit all records in a clear portrait view.

File Upload of Insurance Card (Back)
Please submit all records in a clear portrait view.

Immunizations

Immunizations are MANDATORY for all students and must be submitted prior to the start of class. On-campus resident students must have their shots prior to moving into the residence halls.

New York State Public Health Law states that all students who are registered (full-time) and were born on or after Jan. 1, 1957, are required to submit verification of immunization for one mumps, one rubella, and two measles prior to attending Hilbert College. If we have not received proof of immunization we are mandated to prohibit you from attending classes. Transfer students may submit health records from a prior college. Learn more about immunizations.

Attach verification records of immunization for one mumps, one rubella, and two measles vaccinations.

Upload Immunization Records

Please submit all records in a clear portrait view.

Have You Gotten the Meningococcal Meningitis Immunization Within the Past 5 Years?

Yes, I have gotten the vaccine and will submit proof.

No, I have not and will sign off on the risks.

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Student Medical Form | Enrollment Kit

Student Medical Form | Enrollment Kit

Proof of Health Insurance

Immunizations

Meningococcal Meningitis Vaccination

Physical Examination