Personal Information

Home: Cell:

Parents, Guardian, or Spouse


In Case of Emergency Contact


Family Health History

Does anyone in your immediate family have these health issues? If so, please provide the relationship of the person.

  • I have living brothers
  • I have living sisters

Personal Medical History

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Accommodations Needed

The Office of Academic Support will need documentation of disability on items 4 and 5 that verifies eligibility for services requested.

Personal Immunization Record

Please have your doctor or primary care physician email your immunization records to us at Alternatively, you or your doctor can mail them to:

ATTN: Admissions
Mount Vernon Nazarene University
800 Martinsburg Road, Mt. Vernon, OH 43050

Statement of Affirmation and Consent

By completing this form, and signing it below, I agree to each of the following.

  1. I affirm that the information provided on this form is accurate and complete. I understand that if I knowingly provide inaccurate or incomplete information (a) I release the University of any liability, and (b) providing inaccurate or incomplete information to MVNU can jeopardize my enrollment status and any concerns about disclosure will be reviewed by the Director of Residence Life.
  2. I agree to submit to a complete physical, toxicological, and/or psychological evaluation as a condition of admission or continued enrollment, if requested in writing by Student Health Services or the Director of Residence Life.
  3. I will report changes in medical conditions, medication or new medications immediately to Student Health Services as long as I am a residential student.
  4. I give my permission to be treated by Student Health Services. I understand that information on this form may be used by the Student Life staff in an emergency situation.
  5. I give my permission for university officials to inform my designated “medical emergency contact” in an emergency situation.

Parent or Guardian’s signature (if student is under age 18)