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BMB Health Form
*Confidential* Please submit by August 1, 2021
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
University email address (i.e. @
wmich.edu
, etc.)
*
Your answer
Gender
*
Choose
Male
Female
Prefer not to say
Date of Birth
*
MM
/
DD
/
YYYY
Name of Parent/Guardian
*
Your answer
Parent/Guardian Address
*
Your answer
Parent/Guardian Phone
*
Your answer
Emergency Contact Name (not parent/guardian)
*
Your answer
Emergency Contact Phone
*
Your answer
Relationship to Emergency Contact
*
Your answer
Do you have health insurance?
*
Choose
Yes
No
Not Sure
Indicate any past or present health concerns
*
Epilepsy/Seizures
Dizziness, Fainting
Ear, Eye, Nose, Throat issues
Bee Alergy
Food Allergies
Medication Allergies
Heart Problems
Kidney, Urinary issues
Asthma/Bronchitis
Hepatitis
Stomach issues
Diabetes
None
Other:
Required
Specific Food or Medication allergies
Your answer
Current Medications (if none, answer "N/A")
*
Your answer
Do you prefer vegetarian meals?
*
Yes
No
Vegan/other
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