UNH Student Flu Notification Form

First Name*:
Middle Initial:
Last Name*:
StudentID*:
Cell Phone*:
Email Address*:
Undergraduate/Graduate:	Undergraduate Graduate
If athlete, please select sport(s):	Not athlete Baseball Football Men's Basketball Men's Cross Country / Track & Field Men's Soccer Men's Volleyball Softball Women's Basketball Women's Cross Country / Track & Field Women's Lacrosse Women's Soccer Women's Tennis Women's Volleyball
Resident/Commuter*:	Commuter or Resident? Commuter 1132 Campbell Bethel Hall Bixler Hall Botwinik Hall Dunham Hall Forest Hills New Hall Regency 15 Ruden Street 19 Ruden Street 21 Ruden Street Savin Court Sheffield Hall Soundview Hall Winchester Hall

List any medications you are allergic to:
	Fever over 100 F
	Cough
	Body Aches
	Sore Throat