Alamo Colleges Bacterial Meningitis Vaccination Compliance Form printable pdf download

ALAMO C OLLEGES B ACTERIAL M ENINGITIS V ACCINATION C OMPLIANCE F ORM

PLEASE N OTE: S TUDENTS W ILL N OT B E A LLOWED T O C OMPLETE T HEIR R EGISTRATION U NTIL T HIS F ORM H AS B EEN C OMPLETED A ND A LL R EQUIRED

A LL D OCUMENTATION M UST B E I N E NGLISH

DOCUMENTATION HAS B EEN R ECEIVED A ND P ROCESSED.

E mail t o

E-‐fax t o

M ail t o: San A ntonio C ollege i n c /o I mmunization R ecords C enter

d st-‐bmeningitis@alamo.edu

: ( 210) 4 86-‐9873

1 300 S an P edro, B ox 9 999; S an A ntonio, T X 7 8212

Please u se B lack o r B lue I nk

REQUIRED: STUDENT INFORMATION

Last N ame

First N ame

Alamo C olleges’ S tudent # ( Banner # )

Date o f B irth (MM/DD/YYYY)

Last f our d igits o f S ocial S ecurity #

Gender:

! Male ! Female

Local M ailing A ddress:

Phone:

Y ear A ttending _ __________

Street:_______________________________________

(

)

ACES U ser N ame:

M ark S emester A ttending

! Fall

City:

S tate:_

Z ip

@ student.alamo.edu

Primary C ollege ( Choose O ne)

! Spring

! N LC ! N VC ! P AC ! S PC ! S AC

! Summer

COMPLETE EITHER OPTION 1 O R 2

OPTION 1 : V ACCINATION

S elect T ype o f A ttachment

(A)

I h ave included a copy of my official immunization record for the Bacterial Meningitis Immunization issued by a state or local health

a uthority t hat s hows t he n ame a nd a ddress o f t he a gency, w ho g ave t he v accination a nd t he m onth, d ay a nd y ear o f v accination;

(B)

I h ave included a copy of my official record from a Texas school official or a school official in another state;

(C)

A licensed health care professional, authorized by law to administer the required vaccine, has certified my immunization and has

completed the information below (additional documentation i s not required). T o b e completed b y t he l icensed h ealth c are p rofessional:

Vaccination D ate:____________________

Agency o r H ealth C are

Vaccine T ype

M CV4

M PSV4

B rand N ame _ ________________ L ot # _ ______________

Professional’s S tamp

I c ertify the above named student has received the Bacterial Meningitis Immunization on the date listed above.

Health Care P rofessional’s S ignature: _ _____________________ P rinted N ame: _ ___________________________

Provider’s A gency N ame & A ddress: _ ___________________________________________________________ D ate:

O PTION 2: WAIVER

S elect A pplicable Waiver

T his F orm M ust B e S ubmitted W ith E ach W aiver

(A) ! I a m r equesting a n e xemption f rom t he m eningitis v accination r equirement d ue t o e nrollment o nly i n o nline c lasses a nd h ave i ncluded t he

required A lamo C olleges “ Bacterial M eningitis V accination W aiver f or E nrollment i n O nly O nline C ourses” w aiver w ith t his d ocument.

ttp://alamo.edu/uploadedFiles/District/Admissions/Bacterial_Meningitis/Files/AC-‐Meningitis-‐Online-‐Course-‐Waiver.pdf

(B) ! I n t he opinion of a p hysician the vaccination required would be injurious to m y health and well-‐ -‐ -‐ b eing, t herefore t h e “ M e d i c a l

E x e m p t i o n A f f i d a v i t ” o r a l etter signed by a p hysician duly registered and licensed to p ractice medicine in t he U.S. is i ncluded with

this document. The affidavit or letter must include the date, physician’s n ame, a gency n ame, a nd a ddress.

(C) ! I h ave d eclined t he v accination f or b acterial m eningitis f or r eason o f c onscience, i ncluding r eligious b elief; t herefore a s igned c opy o f t he

“Exemption f rom M eningococcal V accination R equirements f or R easons o f C onscience” f orm i s i ncluded w ith t his d ocument.

https://webds.dshs.state.tx.us/immcojc/

(D) ! I a m c laiming e xemption o n t he b asis o f a ge. I a m c urrently o r w ill b e a ge 2 2 o r o ver b y t he f irst d ay o f t he s tart o f t he s emester i ndicated a bove. I

have i ncluded a c lear p hotocopy o f m y d river’s l icense, b irth c ertificate, p assport o r s tate i ssued i dentification c ard w ith t his d ocument.

I h ave r ead a nd u nderstand t he B acterial M eningitis i mmunization r equirements. I c ertify t hat, t o t he b est o f m y k nowledge, t he a bove i nformation

(including a ny a ttached c opies) i s t rue a nd c orrect. T he A lamo C olleges d o n ot p rovide c opies o f i mmunization r ecord s ubmissions; t herefore, I

understand I m ust m ake a c opy o f a ll d ocumentation s ubmitted f or m y r ecords. I a lso g ive m y p ermission f or t he A lamo C olleges t o s hare t his

information w ith o ther A lamo C olleges o fficials w hen d eemed n ecessary.

STUDENT’S SIGNATURE (or PARENT/GUARDIAN SIGNATURE IF STUDENT IS UNDER THE AGE OF 18)

S tudent S ignature:

Print: _

Date:

For O ffice U se O nly:

A &R T EAM:

IRC T EAM:

F inal A pproval

D ate R eceived______________________ I D C heck _ _____________

Date R eceived & I nitials___________________ I mmunized o r W aiver

H old R emoved _ _______________________ I nitials_________________