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Dear Student:

On behalf of the Health Center Staff, welcome to Cheyney University.   We are writing to advise you of the University requirements for health information and insurance.

Please follow the instructions carefully.  Incomplete records will be returned and this will delay your registration.  There will be no extensions of time granted for incomplete records at registration.

  1. Report of Medical History and Physical Exam Form.

    Pages 1 – 3 are to be completed and signed by the student or guardian (if student is a minor).  The physical exam and immunizations (pages 3 – 4) are to be completed and signed by your physician.  Your high school health office may be able to help you with the immunization records.  There is no substitute for this Medical History and Physical Exam Form.

    Measles, Mumps, Rubella Vaccine:  All entering students should have two doses of the MMR vaccine, the first dose given at 12 months of age or older, and the second a minimum of one month later.  Either MMR or MR or single antigen measles vaccine is acceptable.  Laboratory evidence of immunity is acceptable.

    Tetanus Shots:  Date of shot must be within 10 years of the date of registration.

    Meningitis vaccine:  You must have received the vaccine.

    Polio:  Evidence of immunization or titers.

    Hepatitis B:  Evidence of immunization or titers.

    Varicella: Evidence of immunization or history of disease.

    Tuberculosis:  PPD (skin test) or IGRA (Quantiferon) within 6 months of registration.  If positive, a copy of a chest x–ray and any treatment information is required.

  2. Proof of Medical/Hospital Insurance
    Proof of insurance is required on a yearly basis.  If you have your own insurance or you are covered by your parent’s plan, complete the insurance information.  A photocopy of the front and back of your insurance card must be included.  You will not be able to complete the registration process without proof of insurance.  ANY MEDICAL EXPENSES INCURRED BY THE STUDENT IS SOLEY THE STUDENT’S RESPONSIBILITY.

    If you are in need of health insurance, you may research health plans via the internet.  The Health Center has a brochure of insurance plans that would provide you with basic emergency room coverage.  For more information please call the Health Center (610) 399 – 2260.

    Original completed health forms should be mailed or hand delivered to the Health Center.  Return the completed forms as soon as possible.  If you have any other questions, please call us at (610) 399 - 2260.

Thank you,

The Cheyney University Health Center

1837 University Circle, P.O. Box 200

McKnight & Rogers Building

Cheyney, PA  19319