Lincoln University

Please Note: All students carrying 12 credit hours or more must have Health Insurance.  Choosing yes or no does not represent a waiver.  You may waive the Student Health insurance by going to www.bollingercolleges.com/lincolnuniversity .

Please Note:  Some Insurance policies from outside of Missouri may not cover your medical expenses while you attend Lincoln University of Missouri.  Please check with your provider to ensure you have insurance for general medical needs including prescriptions.

Has any blood relative (Parent, Sibling or Grandparent) had any of the following:

Have you ever been diagnosed with any of the following illnesses or diseases:

If your answer is NO , you can skip this section. 

If your answer is YES , Missouri legislation requires students in university housing to either:

1.  Show documentation of meningococcal vaccine or

2.  Sign a waiver tghat indicates they have been provided educational materieals but have chosen not to recieve the vaccine at this time.

To make an informed decision about receiving the vaccine it is important to read the infomation provided on the following website:

Centers for Disease Control (CDC) www.cdc.gov/nip/publication/VIS/vis-mining.pdf

For students who have received the vaccine:  A copy of the required documentation should be forwarded with your Immunization Record to:

Student Health Center                                                                                                   822 Lee Drive                                                                                                            Jefferson City, MO  65101                                                                                                or via fax to (573) 681-5877

For students who have not received the vaccine:   A waiver is found on the last page of this health form.  Please read waiver statement carefully before submitting this form. 

Please read the statements below.  If you agree with each statement, place a check in the corresponding box. 

ONLY CHECK IF LIVING ON CAMPUS AND WAIVING MENINGOCOCCAL VACCINE