Bacterial Meningitis Immunization Verification Or Exemption Form printable pdf download

Bacterial Meningitis Immunization Verification or Exemption Form

_______________________________ ________________________________

_____/_____/_____

Student Last Name

Student First Name

Date of Birth

Please submit completed document to Undergraduate Admissions or Graduate Studies

I have received the Bacterial Meningitis Vaccine and acquired an official vaccination/shot record to support it.

I understand that proof of vaccination must be in the form of an original vaccination/shot record and include

signatures of administering health professionals, as well as the medical facility stamp and notarization seal.

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Exemption from Immunization for Bacterial Meningitis for Medical Exemption

The Bacterial meningitis Vaccination required would be injurious to the health and well-being of the student. A medical exemption

must be declared a permanent exemption or must be resubmitted annually. Please select:

Permanent Medical Exemption

One Year Medical Exemption starting on ______/______/_______

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Vaccine Verification and Medical Facility information (Completed by Physician/Health Professional)

Type of Vaccination:

MCV4

MPSV4

Other: _______________________

Date vaccination was administered: ______/______/______

Month

Day

Year

I hereby verify/confirm that the above named student received the mandated Bacterial Meningitis vaccine as required, and that the

information provided on this form is true and accurate.

_______________________________

Physicians Printed Name

_____________________________________

Physician Signature

_____________________________________

Physician / Practice Stamp

Date Signed

_______________________________

Practice/Hospital Name:

Phone

Exemption from Immunizations for Bacterial Meningitis for Reasons of Conscience

Students may submit notarized affidavit stating the student declines the vaccination for reasons of conscience, including a religious

belief.

Bacterial Meningitis Immunization Verification Or Exemption Form

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