REQUIRED IMMUNIZATIONS
Student Name ______________________________________________________
(Last) (First) (M.I.) (Maiden)
Social
Security Number ________________________ Date of Birth ___/___/___
Current
Address ____________________________________________________
IMMUNIZATIONS (Dates must be listed)
Physician Diagnosed Serology Date/
Disease Vaccine Date Disease History (onset date) Results
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Measles * |
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Rubella * |
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Mumps * |
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or combined as MMR |
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I
certify that the above is complete and accurate to the best of my knowledge.
Health
Care Provider:
_______________________________________
Print or Type
_______________________________________
Signature
Title:
________________________________________
Telephone:
___________________________________
*New York State law requires college students to be immunized against measles,
mumps and rubella. The law applies to all students born on or after Jan. 1, 1957.
_________________
Date
Form Completed