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. Current Personal 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 MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall 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 2020 2021 2022 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 All undergraduate students enrolled in a program of study leading to an academic degree and born after 1956 must provide the college with proof of having received two injections of Measles, Mumps and Rubella vaccine, either separately or as a combined MMR vaccination, or laboratory proof of immunity to each of these infections. Beginning with the 2008-09 academic year, all new students must be vaccinated for Hepatitis B (a series of 3 shots) within nine months of attendance as a condition or continued attendance at Bloomfield College. Three Hepatitis B vaccinations complete the series. As a service to Bloomfield College students, the Bloomfield Board of Health is pleased to offer vaccinations, needed for college, at a reduced cost. Arrangements can be made with the school nurse. More information can be found here.