Immunization Form - Northwestern Oklahoma State University
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3NWOSU IMMUNIZATION RECORD
709 Oklahoma Blvd. Alva, OK 73717
Name
Last
First
Middle
Date of Birth
Sex
M
F
S.S.#
Date of Entrance to NWOSU:
Fall
Spring
Summer
Year
Status: Part-Time
Full-Time
Graduate
Undergraduate
Professional
Permanent Mailing Address
Street
city/state/zip
IN CASE OF EMERGENCY, NOTIFY:
Parent, guardian, or next of kin:
Phone #s
(
)
Address:
Street
city/state/zip
If you attach your immunization records, do not complete this section.
MMR
#1
/
/
#2
/
/
(Measles, Mumps, Rubella)
Mo Day Yr
Mo Day Yr
Hepatitis B Series
#1
/
/
#2
/
/
#3
/
/
Mo Day Yr
Mo Day Yr
Mo Day Yr
Meningococcal
(required only if living on campus)
/
/
Mo Day Yr
Oklahoma law requires all students to provide immunization information or sign a religious/moral exemption.
If you can answer “yes” to any of the following questions, you are not required to submit your immunization records.
DID YOU GRADUATE FROM AN OKLAHOMA HIGH SCHOOL AFTER 2002? ____YES ____NO
IS YOUR DATE OF BIRTH BEFORE 1957? ____YES ____NO
I AM ENROLLED ONLY IN COURSES DELIVERED VIA THE INTERNET OR DISTANCE LEARNING. (DOES NOT
APPLY IF TAKING CLASSES AT THE ALVA, ENID, OR WOODWARD CAMPUS) ____YES ____NO
I HAVE SERVED IN THE U.S. ARMED SERVICES AND HAVE BEEN VACCINATED AS REQUIRED BY OKLAHOMA
STATUTE, TITLE 70 § 3244. ____YES ____NO
I HEREBY STATE THAT ALL OF THE INFORMATION GIVEN IN THIS DOCUMENT TO THE BEST OF MY
KNOWLEDGE TO BE TRUE.
SIGNATURE____________________________________________________DATE__________________________________
Moral or Religious Exemption: Parent or guardian of the above named person or the person himself/herself has an adherent
moral or religious belief opposed to immunizations.
SIGNED________________________________________________________DATE___________________________________
(Parent, guardian, emancipated student or student 18 years or older)
*In the event of an outbreak, students without proof of immunization may not be allowed to attend class or other
group activities.
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