Seizures: ___
Chronic Diseases: ___
Allergies: ___
Medications: ___
Significant Historical Information:
1/2
Polio Series (x4)
Adult Tdap (not older than 10 years)
Meningitis Vaccine (up to age 26) – Meningococcal Quadrivalent (A, C, Y, W-135) and Serogroup B Meningococcal Vaccine
Mumps (MMR x 2 or documentation of disease)*
Varicella Vaccine x 2 or History of Chickenpox*
Tuberculin Skin Test (INTERNATIONAL STUDENTS ONLY)
Hepatitis B Series x 3
*Note: Documentation of disease should be verified or signed on physician's/clinic's letterhead.
Note: Documentation from Physician and Parent – NO Immunizations because of religion
Recommended immunizations include:
Hepatitis A Vaccine
HPV Vaccine
Pneumococcal Vaccine
Must submit certificate from Doctor's office/clinic as documentation of proof of all immunizations to address or fax number on front.
(Rev 6/19)