Updatedimmunizationsform-fillable-09-15-2021

.pdf
School
Georgian College **We aren't endorsed by this school
Course
GNED MISC
Subject
Nursing
Date
Mar 20, 2023
Pages
1
Uploaded by SuperHumanGerbilPerson379 on coursehero.com
Office of Student Affairs 500 Rutherford Avenue Boston, MA 02129 Phone: 617-873-0614 [email protected] Proof of Immunizations-Massachusetts In compliance with the Department of Public Health, all new and returning students at Cambridge College locations in Massachusetts MUST complete this form before beginning classes. Make an appointment with your physician to get all the vaccinations and/or serology tests listed on this form. Please complete and sign this form at that time. Every dose and date of each immunization l isted on this form are REQUIRED. Student and physician/nurse must SIGN below. Last name: ________________________________________ First name: ____________________________ Middle name: __________________ Current address: _______________________________________________________________________________________ Apt. ___________ City: ____________________________________________ State: __________________ Zip code: _______________________ Phone: __________________________________ Email: __________________________________________________ Date of Birth: _________________________ (MM/DD/YYYY) Immunizations required (provide a date for each dose of every vaccination below: Student signature: __________________________ Date (mm/dd/yyyy): ________________________ Official signatures Physician/Nurse name __________________________________________ Board of Registration in medicine number: _________________________ Medical practice name: _________________________________________ Address: ____________________________________________________ Physician/Nurse signature: ______________________________________ Date (mm/dd/yyyy): ________________ Please complete, sign and return to: Mail: Cambridge College Assistant Dean of Student Affairs 500 Rutherford Avenue Boston, MA 02129 Student ID#: Exemptions: The only circumstances in which you may be exempt from the Massachusetts College Immunization Law are: Birth before 1956 Your physician, who had previously examined you, is of the opinion that your health would be endangered by the required immunizations (you must submit a letter from your doctor) Conflict with religious beliefs (written statement required) TWO MMR (Measles, Mumps, Rubella) vaccines: MMR dose 1: _____________ MMR dose 2: ___________________ OR serology test date: ________________________________ □ OR birth before 1957 in the US ONE Tdap (tetanus, diphtheria, pertussis) booster: □ Tdap date: _______________ Or TD date: _____________________ THREE Hepatitis B vaccines (Adolescent series 2 doses): Dose 1: ____________ Dose 2: _____________ Dose 3: _______________ OR serology test (titer) date: _________________ Mark here if adolescent series TWO Varicella (Chicken Pox) vaccines: Dose 1: ___________________ Dose 2: ______________________ OR Chicken Pox disease date: _____________________________ OR Varicella titer date: __________________________________ OR birth before 1980 in the US I am a full-time student: Undergraduate taking 12 credits or more per academic semester; Graduate taking 8 credits or more per academic semester; I am a part-time student, taking fewer credits per academic semester; Academic program: _________________________________School: ____________________ E-mail to [email protected], write "Immunizations" in the subject line.
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