MEDICAL HISTORY

Seizures: ___

Chronic Diseases: ___

Allergies: ___

Medications: ___

Significant Historical Information:

1/2

Required complete immunizations to submit:

• 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)