Certificate Of Immunization - Southwest Tennessee Community College printable pdf download

Certificate Of Immunization - Southwest Tennessee Community College

CERTIFICATE OF IMMUNIZATION

Full-time Students Only

The State of Tennessee requires students entering a state college or university to show proof of having two doses

of the Measles, Mumps, and Rubella (MMR) and Varicella (chicken pox) vaccines unless they fall into one of the

exempted categories. A student may be exempt if they can prove that they have had the disease, are immuned,

opposed to the vaccination based on religious doctrine, or have documentation that the vaccine is medically

unadvisable.

The Certificate of Immunization form must be completed and signed by a licensed medical doctor or licensed

health care provider. An official copy of a state health department or military immunization form will be accepted

with a valid date. A student will not be allowed to register for 12 or more credits until an acceptable proof of

immunization has been submitted to the Office of Admissions and Records.

Student name_______________________________

Student ID/SSN__________________ Telephone________________

PART I

EXEMPTIONS

Please check one of the following exceptions, if applicable, and sign.

o I certify that I was born prior to January 1, 1957, therefore exempt from the MMR requirement.

o I certify that I attended a TBR college or university full time for at least one semester after August 1, 2007,

therefore exempt from the MMR requirement.

List college and attendance date_____________________________________________________________

o I certify that I was born prior to January 1, 1980, therefore exempt from the Varicella requirement.

o I affirm under penalty of perjury that I have not and/or will not obtain(ed) vaccinations because it conflicts

with my religious practices.

o I am classified as active duty military personnel and have attached proof of my active duty status.

o I will only be enrolling in on-line classes, therefore I am exempt from the immunization requirement.

Signature_______________________________________________________

Date____________________

Certificate Of Immunization - Southwest Tennessee Community College