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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.