Apply Today   Visit Today

Health Forms

In order for the Clarke Health Center to provide competent and thorough treatment, we require a COMPLETED HEALTH FORM for each full time student. This form must be on file in the Clarke Health Center one month prior to the student's arrival. If it is not, your Elmira College account will be charged a fee of $100.00. An additional fee of $100.00 will be added each month until the COMPLETED Health Form is received.

The Health Form should be completed and returned by mail to the Clarke Health Center one month prior to the student's arrival.

The Health Form must include:

  1. Completion of the first two pages by the student. Please note student signature requirement on the bottom of page two.
  2. Completion of the College physical exam on page three performed by a physician, nurse practitioner, or a physicians' assistant, which must be within six months of arriving to Campus.
  3. Completion of page four (i.e. the immunization record) with the signature of your health care provider.
    a) Measles, Mumps, and Rubella requires two MMRs or dates of positive titers
    b) Meningococcal vaccine and booster of first does prior to age 16.
    c) Varicella vaccine and booster if you have never had the chicken pox or positive Varicella titer date. New York State Department of Health mandates the date of chicken pox disease if applicable.
    d) Tetanus vaccine history of primary series and booster within ten years. (minimum of three)
    e) Polio vaccine history of primary series and booster. (minimum of three) or positive titers.
    f) Hepatitis B Series of three vaccines or date of positive Hepatitis surface antibody.
    g) PPD within the last six months (skin test to screen for tuberculosis). Please note, any positive PPD reading will require a chest x-ray on or after the date the PPD. The public health department or pulmonologist work-up needs to be sent including documentation that anti-TB medication was discussed and offered to the student. The copy of the chest x-ray report needs to be sent with the Health Form. Please list BCG vaccine if applicable.

IMPORTANT: If documentation of proof of immunity against Measles, Mumps and Rubella and the Meningitis vaccine is not on file at the Clarke Health Center within thirty days of the start of classes, you will be withheld from attending classes until in compliance with New York State Public Health Law #2167 and #2165.

All new full-time students need to complete the following health form and return it to the Clarke Health Center:

Elmira College Health Form

Notice of Privacy Practices