Health Clearance Form Please fill out the form below. If you wish to fill out a printable form,please click here to download the PDF form. You must have JavaScript enabled to use this form. CurrentPersonal Information Immunization Information Complete Contact Information First Name Last Name Email Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinois印第安纳州IowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Date of Birth Last 4 Digits of Social Security Number Year of Entry 2024 2025 2023 Student Type Part-Time Full Time First Year Transfer Undergraduate RN Resident Student Commuter Student Are you a current Bloomfield College student? - Select -YesNo Bloomfield College ID# New Jersey State Law You must submit proof of the following immunization records in order to move onto campus and to attend classes: All students must submit proof of 3 Hepatitis B vaccines, 2 MMR vaccines, 1 meningitis ACYW since age 16+. Residential students must also submit proof of COVID-19 vaccination (2 doses of the original COVID vaccination or the updated COVID bivalent vaccination will be accepted).