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KENTUCKY STATE UNIVERSITY

IMPORTANT NUMBERS:

Financial Aid 502-597-5960

Admissions

502-597-6813

Residence Life

502-597-5951

Bursars Office

502-597-6278

Athletics

502-597-6011

Campus Police

502-597-6877

Student Health Services 502-597-6271

Kentucky State University is committed to a policy of providing education opportunities to all qualified students regardless of economic or social status and will not discriminate on the basis of race, color, ethnic origin, national origin, creed, religion, political belief, sex, sexual orientation, marital status, age, veteran status, or physical or mental disability. Rev. 01/21/16

Intent to Enroll Response Form

Complete Intent to Enroll Response Form online or mail to Office of Admissions Kentucky State University 400 E. Main St. Frankfort, KY 40601

_ I intend to enroll at Kentucky State University in □ Spring □ Fall Semester _____ Year

Spring Fall Semester ___ Year

I do not intend to enroll at Kentucky State University in □ Spring □ Fall Semester _____ Year

Spring Fall Semester ___ Year

Campus Wide ID # (see acceptance letter):

Print Name (Last, First, Middle)

Home Address (number and street)

City

State

Zip Code

Mailing Address, if different from above (number and street)

City

State

Zip Code

Home telephone (with area code): _____

Cell phone (with area code): _____

Email address: ___

Alternate email address:

The quick brown fox jumps over the lazy dog.

Signature Date

12/21/2016

Consent to Release Educational Records

I, ___, understand that the Family Educational Rights and Privacy Act (FERPA) grants me certain rights concerning my education records. Notwithstanding these rights, I consent to the release of my educational records to my parent(s) or guardian(s) listed below for the purpose of keeping them informed about my education at Kentucky State University. I understand that education records include, but are not limited to, information about my academic standing, disciplinary issues, and financial obligations to the University.

This consent will remain in effect until I graduate or withdraw from the University. I understand that I may submit a subsequent notification in writing directing the University to no longer release information to any or all of the individuals listed below.

Kentucky State University is authorized to release educational information to the following individuals: Name

Relationship to Student

Relationship to Student

Relationship to Student

Student Name

Student Signature

Student Date of Birth

Student ID

Name Relationship to Student

Name ___

___

Name

___

Date

Rev. 2/17/16

Dear Thorobred:

Student Health Services recommends all students submit the Medical History Form, Preventative Health Care Examination Form, and an Immunization Record prior to attending Kentucky State University.

Documentation from a doctor or clinic regarding the following immunizations is recommended:

• Preventative health care examination completed by doctor or clinic within the past six months
• Tuberculin Skin Test within the past six months
• Copy of chest X-ray if history of positive tuberculin test

Recommended immunizations include:

• Polio Series (x 4)
• Adult Tdap (within the past 10 years)
• Meningitis Vaccine (up to age 26)
• Mumps (MMR x 2 or documentation of disease)
• Varicella Vaccine/Chicken pox (x 2 or documentation of disease)

Note: Documentation of disease should be verified or signed on a physician's or clinic's letterhead.

Please send the following completed forms and immunization record to:

Office of Admissions Kentucky State University ASB Suite 312 400 E. Main St. Frankfort, KY 40601

Or fax to: (502) 597-5814

Thanks for your cooperation!

Sincerely,

Floarine A. Wilson, APRN Director, Betty White Health Center

Rev 2/22/16

Medical History Form

INSTRUCTIONS AND INFORMATION:

1. We recommend this form be returned to the address below within 30 days or no later than 14 days prior to enrollment. All pages must be completed.
2. We recommend this form be completed by all new students and students who have been away from the University for more than 10 months. We also recommend students entering graduate school complete this form.
3. Information on this form is CONFIDENTIAL, is for Kentucky State University Student Health Services, will not be released without the student's consent, and will not affect admissions status.
4. Send completed forms to: Office of Admissions

Kentucky State University

ASB Suite 312

400 E. Main St.

Frankfort, KY 40601

Fax: (502) 597-5814

IDENTIFICATION

ID Number (see acceptance letter): ___

Name (last, first, middle)

Home Address (number and street)

City State

Zip Code Country

Home Telephone: (_____)

Cell Phone: (___)

Email: ___

Date of Birth (Month-Day-Year): ___

Sex (optional): ☐ Male

Female

Emergency Contact: ___

Emergency Contact Phone Number: (____) _____

Rev 2/22/16

Medical History Form

Seizures: Yes No Comments: ___

Chronic Diseases: ___

Allergies: ___

Drug Allergies: ___

Medications: ___

Significant Historical Information: ___

IMMUNIZATIONS:

We recommend a certificate from a doctor's office/clinic as proof of immunization.

1. Tdap (tetanus/diphtheria/pertussis): Recommended within the last ten years.
2. Polio Series: Recommended if student is 18 years or younger.
3. Mumps: Recommended immunization if no history of illness.
4. Measles (rubelola): Recommended documentation of two MMR vaccines. Either a certificate of immunization dated 1969 or later or proof of positive titer suggested. Copy of lab report may be submitted. History of illness is not sufficient.
5. Tuberculin Skin Test: Recommended within six months prior to start of class. The documentation should state the test results were negative or positive. CHEST XRAY IS STRONGLY RECOMMENDED EVERY YEAR IF TUBERCULIN SKIN TEST WAS REPORTED POSITIVE.
6. Menactra / Meningitis: Vaccine is recommended for all incoming new students up to age 26. Vaccine is also recommended for older or transferring students living on campus.
7. Varicella (chickenpox): Recommended to have two vaccines or history of the chickenpox disease prior to starting KSU.

HEALTH HISTORY AND PHYSICAL ASSESSMENT

Students who submit the health history form or copy of past immunizations will be notified of the immunizations that need to be updated prior to the start of class. Students should submit the health history form completed by a doctor's office or clinic within the past six months.

Rev 2/22/16

Preventative Health Care Examination Form

IDENTIFYING INFORMATION

Student Name (last, first, middle) ___

ID Number: _____ Date of Birth: _____

MEDICAL HISTORY

Seizures: ___

Chronic Illness: ___

Allergies: ___

Drug Allergies:

Medications: ___

Significant Historical Information: ___

___

PHYSICAL EXAM:

N Abn

Hgt:_____ Wgt:_____ BP:_____/_____

___ ___ General Appearance

___ ___ HEENT Hearing: R ___ L ___

___ ___ Skin Vision: R ___/___ L ___/___

___ ___ Neck

Optional:

___ ___ Chest

HCT/HGB: ___ UA: ___

___ ___ Heart

___ ___ Abd-Genitalia

___ ___ Extremeties-Back (including scoliosis for 6^{th} grade)

___ ___ Neuro

Explain Abnormal Exam: ___

___

RECOMMENDATIONS:

___ No restrictions - normal exam

Restrictions and suggestions to school:

___

Signed: ___ Date: ___

Physician/ARNP/PA/EPSDT Provider

Address:_____ Telephone: _____

Mail completed form to: Office of Admissions, Kentucky State University, ASB Suite 312,

Office of Admissions, Kentucky State University, ASB Suite 312,

400 E. Main St., Frankfort, KY 40601 or fax to (502) 597-5814

Rev 2/22/16