Forms and ApplicationUniversity Health Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the participant's NAME and DATE OF BIRTH in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the HOME STREET ADDRESS, CITY, STATE, and ZIP CODE. This helps the University Health Center contact you if necessary.
4. Indicate GENDER and select the PROGRAM you are enrolling in from the dropdown menu.
5. Provide a PHONE number where you can be reached, along with a PROGRAM CONTACT PERSON's details for emergencies.
6. Authorize diagnostic and treatment procedures by filling in your name and program details under the PERMISSION section.
7. Complete the EMERGENCY CONTACT section with names, relationships, addresses, and phone numbers of individuals to notify in case of an emergency.
8. Fill out PRIMARY INSURANCE INFORMATION if applicable. Attach a copy of your insurance card as instructed.
9. Review all entries for accuracy before submitting. Once completed, save your form and send it via fax to ensure timely processing.

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