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Health Information Request Form

Complete this form to request that CCC send your health information (including immunizations) we have on file.

First Name *

Last Name *

Student ID number or last 4 digits of social secuity number: *

Date of Birth (mm/dd/yyyy): *

Contact Phone Number: *

 Check here if you wish to have your record faxed.

Name of Person/Office to send to:

Fax number:

 Check here if you wish to have your record picked up at the Counseling & Advisement Office (Room 146M)

Name of Person picking up record:

By clicking submit, I understand that this is an electronic signature authorizing consent for Clinton Community College to release a copy of your immunization records as requested.