Immunization Form - Northwestern Oklahoma State University (Page 2 of 3) in pdf

Immunization Form - Northwestern Oklahoma State University Page 2

Hepatitis B Statement

I agree and understand that I must complete the hepatitis B shots (3) before the

next academic semester begins. I further understand that I will not be allowed to

enroll for the next semester until the hepatitis B immunization is completed (three

shots). The hepatitis B immunization series of shots takes four months to

complete. I will provide proper documentation to the Northwestern Registrar’s

office upon completion of the hepatitis B immunization.

(Complete only if you have not taken the hepatitis B immunizations.)

_____________________________________

__________________

Student (Print Name)

Date

_________________________________________________________________

Address (while attending NWOSU)

_________________________________________________________________

City

State

Zip Code

_________________________________________________________________

Address (permanent)

_________________________________________________________________

City

State

Zip Code

_________________________

_____________________________________

Phone number (local)

e-mail address

________________________

Phone number (permanent)

________________________

Student (sign name)

Immunization Form - Northwestern Oklahoma State University Page 2