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ITASCA COMMUNITY COLLEGE
IMMUNIZATION
RECORD
For Students Attending Post-Secondary Schools
Students born prior to 1957 and students
who graduated in 1997 or thereafter from a Minnesota high school do not need to
provide immunization records. All other students must provide documentation of
immunization against these vaccine preventable diseases: measles, rubella,
mumps, diphtheria, and tetanus.
Please complete this immunization form and
submit with your application to Itasca.
Name_______________________________________________
Last
First MI |
Soc. Sec.
#___ ___ ___ - ___ ___ - ___ ___ ___ ___ |
Birthdate ______ / ______ / ______
mo day
year |
Enter the month, day (if available), and year of the
most recent "booster" for diphtheria and tetanus (must be within the last 10
years) and for all doses of vaccine for measles, mumps, and rubella that were
given after 12 months of age.
| Diphtheria & Tetanus
(Td) |
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| Measles (rubeola, red
measles) |
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| Rubella (German measles) |
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For the student: I certify that the above
information is a true and accurate statement of the
dates on which I received the immunizations
required by Minnesota law.
Student's
signature_________________________________________
Date_______________
Students wishing to file an exemption
to any or all
of therequired immunizations must complete the
following:
Medical exemption: The student
named above does not have one or more of the required
immunizations because he/she has (check
all that apply):
c
A medical problem that precludes the
______________________________vaccine(s).
c Not been immunized because
of a history of __________________________disease.
c Laboratory
evidence of immunity against____________________________________.
Physician's signature___________________________________________
Date________________
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Conscientious exemption: I hereby
certify by notarization that immunization against
__________________________________is contrary to my conscientiously held
beliefs.
Signature of student____________________________________________
Date______________
Subscribed and sworn before me on the _________
day of _____________________, 20_______.
Signature of
notary______________________________________________________________
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