Certificate Of Immunization Form
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1C E R T I F I C A T E O F I M M U N I Z A T I O N
Make a copy of this form to keep with your important papers.
COLLEGE
As required under University System Policy, this form must be completed and returned to Darton
before the student will be eligible for enrollemnt.
Part A - To be completed by the student (please print).
Name
Expected date of
[ ] Fall
[ ] Spring
(last, first, middle, Jr., III, etc.)
Darton enrollment
[ ]Summer 20_______
Home Mailing Address
Sex: (optional)
[ ] Male
[ ] Female
Date of Birth
Social Security Number
Home Physician
City, State
Part B - To be completed and signed by a health care provider.
REQUIRED IMMUNIZATIONS
I. MMR (Measles, Mumps, Rubella)
III. Varicella - Note: Required for U.S. students born in 1980 or later.
____1. Dose 1 - Immunized at 12 months of age or later.
Required for all foreign born students.
AND
(MO/DAY/YR)
____/____/_____
____2. Dose 2 - Immunized at least 30 days after dose 1.
____1. Had disease, confirmed by health care provider.
(MO/DAY/YR)
____/____/_____
OR
(MO/YR)
____/_____
OR
____2. Has laboratory evidence of immune titer (specify date of titer).
Measles
OR
(MO/YR)
____/_____
____1. Had disease, confirmed by physician diagnosis in office record.
____3. One dose given at 12 months of age or later but before the student’s
OR
(MO/YR) ____/_____
13
birthday.
(MO/DAY/YR)
____/____/_____
th
____2. Has laboratory evidence of immune titer (specify date of titer).
OR
OR
(MO/YR) ____/_____
____4. Two doses. Dose 1 given after the student’s 13th birthday; second
____3. Immunized with live measles at 12 months of age or later.
dose one month after first dose.
AND
(MO/DAY/YR)
____/____/_____
(MO/DAY/YR) 1. ____/____/_____
2. ____/____/_____
____4. Immunized with second dose of live measles vaccine at least 30 days
IV. Hepatitis B - Note: Required of all students who are 18 years of age or younger.
after first dose.
(MO/DAY/YR)
____/____/_____
(Completion Dates)
Mumps
____1. Had disease, confirmed by physician diagnosis in office record.
____1. Three doses hepatitis B series.
(MO/DAY/YR) ____/____/_____
OR
(MO/YR) ____/_____
OR
____2. Has laboratory evidence of immune titer (specify date of titer).
____2. Three doses combined hepatitis A and hepatitis B series.
OR
(MO/YR) ____/_____
OR
(MO/DAY/YR) ____/____/_____
____3. Immunized with live mumps at 12 months of age or later.
____3. Two doses of hepatitis B series of Recombivax.
(MO/DAY/YR)
____/____/_____
OR
(MO/DAY/YR) ____/____/_____
Rubella
____4. Has laboratory evidence of immune titer (specify date of titer).
(MO/DAY/YR) ____/____/_____
____1. Has laboratory evidence of immune titer (specify date of titer).
OR
OR
(MO/YR) ____/_____
____Over 18 years of age at matriculation.
____2. Immunized with live rubella at 12 months of age or later.
(MO/YR) ____/_____
Immunization status certified by:
OR
Exemption
________________________________________
_________________
____I was born before 1957, and therefore am exempt from the above
Signature of Health Care Provider
Date
requirement.
___________________________________________________________________
II. Tetanus-Diphtheria
Name of Health Care Provider
_____1. One TD booster dose within the last ten years.
OR
(MO/DAY/YR)
____/____/_____
___________________________________________________________________
_____2. Completion of primary series (DTaP, DTP or TD) within the past
Address of Health Care Provider
10 years prior to matriculation.
Completion date
(MO/DAY/YR)
____/____/_____
Phone (__________) _____________-_________________________
MEDICAL EXEMPTION
_____This student is exempt from the above immunizations on grounds of permanent medical contraindication.
_____This student is exempt from the above immunizations until ____/____/_____. Reason ________________________________________________
Return Form To:
_____
Religious Exemption:
I affirm that immunization as required by The University System of Georgia is in conflict with my
religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
Office of Admissions
_____
Distance Learning Exemption:
I declare that I will be enrolling in ONLY courses offered by distance learning. I understand
Darton College
that if I register for an on-campus course, this exemption becomes void and I will be excluded from class until I provide proof of
2400 Gillionville Road
immunization.
Albany, GA 31707-3098
__________________________________________________________
____________________________
Signature of Student
Date
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