You can not save information on the health form.
If you want to submit the form electronically (email) you will need to print the form and scan it back to your computer.
|Click on the link below for the Valparaiso University Health Form.||All students competing in NCAA Athletics must complete the form below|
|Health Form||Athlete Health Form|
All forms must include provider's signature or include supporting document for proof of immunizations.
Submit completed forms to: Valparaiso University Health Center, 55 University Drive, Suite 102, Valparaiso, IN 46383 Fax: 219-464-5410 or Email: firstname.lastname@example.org
It is the law that young adults attending post-secondary schools in the State of Indiana be immunized against or show proof of immunity to certain vaccine preventable and communicable diseases (IC 20-12-71). Valparaiso University requires all full-time undergraduates and full-time law students and ALL international students to complete the Health Form. You will find links below for the Health Form. The Health Form must be completed by the first day of classes. If your completed Health Form is not submitted by the first day of classes you will be assessed a $50.00 fine. Students who do not turn in the completed Health Form within two weeks after classes begin will additionally have a hold placed on their academic account. The hold will prevent the student from accessing grades and registering for classes.
All Health Forms must be in English. The form must include a provider signature for immunizations or official immunization documentation may be attached to the Health Form. All students must provide proof of 2 MMR (measles, mumps and rubella) and a current TD (tetanus, diphtheria). Tuberculosis testing is required of all International students and any domestic student who has lived or had extensive travel to a high prevalence country, including Africa, Asia, Philippines, Indonesia, Eastern Europe, Latin America, Mexico, Portugal, Caribbean and the Middle East.
MMR - The first MMR must be given after 12 months of age. The second MMR must be given at least one month after the first dose.
TD - The TD must be given within the last 10 years. The TDap (tetanus, diphtheria, pertussis) vaccination is preferred.
Click here for Valparaiso University immunization policy and the necessary forms to apply for immunization exemption. If you file an exemption you will still need to complete the Health Form above.: Immunization Exempt Forms