Forms

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Health and Consent Forms

• Health History Form - to be completed online at the Health Portal by all students and new patients.
• Notice of Privacy Practices (NPP) and Consent Form:
   - Students must complete the form online at the Health Portal.
   - Patients that are not FIT students must complete the NPP and Consent paper form (.pdf).
• Parental Consent Form - to be completed online at the Health Portal by parents/guardians of students under the age of 18.

Immunization Forms

Click here for information on immunization requirements.

• Immunization Form (.pdf) 
• Meningitis Information Response Form (.pdf) 

Immunization Exemption Forms

Limited medical and/or religious exemptions for new students will be considered. The deadline to submit exemption requests for Spring 2023 is December 6, 2022, 11:59pm.

All requests received by the December 6th deadline are considered and reviewed, but approval is not guaranteed. Decisions are final, not subject to appeal, and will be shared in a determination letter sent to your FIT email.

Requests received after the deadline will not be considered.

• Request for Religious Exemption to Measles, Mumps and Rubella Immunization Requirements (.pdf)
• Request for Religious Exemption to COVID-19 Immunization Requirements (.pdf)
• Request for Medical Exemption to NY Immunization Requirements (.pdf)
• Remote Learning Attestation Form (.pdf)

Insurance and Prescriptions

• Aetna Medical Claims Form (.pdf)
• Aetna Prescription Drug Claim Form (.pdf)
• Aetna Medication Mail Order Form (.pdf)
• Aetna Dependent Enrollment Form (.pdf)

Medical Records Release Authorization

• Consent to Share Health Information between FIT Health Services and Counseling Center - available online at the Health Portal.
• Authorization to send records to FIT Health Services (.pdf) 
• Authorization to send records from FIT to another medical office/facility (.pdf) 

Advance Directive

• Advance Directive - Planning for Important Healthcare Decisions 

Housing

• Request for housing based on extenuating circumstances

Food Pantry

• Food Pantry Intake form
• Food Pantry Terms & Conditions (.pdf)

 

FIT takes various measures to protect personal data, including fulfilling its obligations under federal, state, and local law, as well as under the European Union’s General Data Protection Regulation to the extent it is applicable. The GDPR provides protections for various information and records while a person is located in the EU. FIT provides notice to students, employees, and website users of what type of data FIT processes and how and why that data is used and shared through information posted on the GDPR page of ’FIT’s Privacy website. Please review the applicable notice(s) carefully. The Privacy website also contains useful information about other privacy policies, such as FERPA and Information Technology’s Privacy Policy, and terms and conditions for the use of the FIT website and social media.