University Health Center Forms

Allergy Extraction Letter and Administration Form - Required for the administration of allergy serum injections at the UHC. Sample of completed form.

Assumption of Risk Form - For students who are not receiving the COVID-19 vaccine due to medical conditions, religious beliefs or other reasons.

Fine Appeal Form - For students who want to appeal a fine placed by the UHC on their account.

First Aid Kit Loan Request - The UHC has first aid kits to loan JMU student groups for travel.  The designated JMU Faculty/Staff advisor for the group may request kits with this form.

Grievance Policy and Form - For students who would like to formally make a complaint or grievance regarding their dissatisfaction with the UHC.

Health Information Receipt - For students requesting a copy of their entire health record. Requires a $10 fee and must accompany the Health Information Release Form.

Health Information Release - For FORMER students requesting any portion of their health record. Current students can do this from MyJMUChart (formerly MyJMUHealth).

Hepatitis B and Meningitis Immunization Waiver - Needed for any student who would like to waive these vaccines.

Immunization Form - State required, must be signed by a health care provider and uploaded as a .pdf to MyJMUChart. Non-compliance will result in $50 fine and academic hold.

Translated Immunization Forms - Available in Arabic, Chinese, French, German, Italian, Japanese, Korean, Russian, Spanish, Thai and Vietnamese.

Medication/Order Authorization - For students who are prescribed an injectable medication that needs to be administered in our Nurse Clinic.  An example of an injectable medication is Vitamin B-12.

Religious Exemption Form - For students exempting immunizations due to religious reasons.