Immunization History

Immunization History Form for WWU Students

Name*

First Name

Last Name

Email*

WWU ID#*

Date of birth*

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Phone number*

I am at least 18 years old*

Yes No

Students under 18 years of age must have this form signed by a parent or guardian.

Required vaccines

For each vaccine, record the date it was administered.

MMR #1 (Measles, Mumps & Rubella

MMR #2 ( Measles, Mumps & Rubella

Tdap (Tetanus, Diphtheria & Pertusssis)

Recommended vaccines

For each vaccine, record the date it was administered.

Meningococcal

Meningococcal disease requires close contact to spread so is a concern on college campuses, especially for students living in residence halls. In Washington state fewer than 20 cases occur each year.

Off to College pamphlet regarding Meningococcal disease.

Polio

Hepatitis A

Hepatitis B

Varicella (Chickenpox)

Human Papillomavirus

Confirmation

STUDENT CONFIRMATION - STUDENTS AGE 18 AND OLDER I certify that I have been immunized for the vaccines noted above. I confirm that I have reviewed a copy of the "Off to College" pamphlet regarding Meningococcal disease.

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PARENT OR GUARDIAN CONFIRMATION - STUDENTS UNDER AGE 18 I certify that this student is under age of 18 and has been immunized for the vaccines noted above. I confirm that I have reviewed a copy of the "Off to College" pamphlet regarding Meningococcal disease.

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MEDICAL, RELIGIOUS OR PERSONAL EXEMPTION TO VACCINE REQUIREMENT

Individuals wishing to be exempted from the vaccine requirement must complete and submit a certificate of exemption. Fax or email completed certificate to WWU Clinic.