Get Albertus Magnus Immunization Form

Please mail all health forms to Albertus Magnus College Dean of Student Services 700 Prospect Street New Haven CT 06511 STATE LAW REQUIRES THAT THIS FORM BE COMPLETED AND ON FILE WITH THE COLLEGE PRIOR TO ATTENDING CLASSES. Pre Admission Immunization Requirements Please Print or Type Name of Student Last First Middle Address Street City/Town State Zip Home Phone Emergency Phone Birth Date M F Sex Parent or Guardian Last First Middle Physician s Name IMMUNIZATION HISTORY Must be Completed by a Physician Record of Immunization Primary Immunization Series Vaccine Type 1st Dose MO/DAY/YR. 2nd Dose 3rd Dose 4th Dose TD Adult Oral Polio Measles Rubella Mumps 1 Physician Statement of Verification 2 Laboratory Verification for Disease History I certify that this student has received the immunization s indicated Physician s Signature Date. MEASLES/RUBELLA IMMUNIZATION CERTIFICATION INFORMATION SHEET This is to inform you that the Public Act 89 - 90 requires all Connecticut college students born after December 31 1956 provide the Health Office with documentation of adequate immunization against measles and rubella* As a result Albertus Magnus College must take the necessary measures as mandated by the state statue. Adequate immunization according to State Statue MEASLES All new and readmitted students born after December 31 1956 must provide proof of two 2 doses of measles vaccine - one dose administered after January 1 1969 and after the students first birthday. The second dose of measles vaccine required to be given at least 30 days after the first dose. RUBELLA German Measles one 1 dose administered after the students first birthday is considered adequate immunization* Students registering at Albertus Magnus College will be required to bring proof of immunization for measles and rubella prior to registration* ANY STUDENT NOT SHOWING THE NECESSARY PROOF OF IMMUNIZATION WILL NOT BE ABLE TO REGISTER* One of the following documents in necessary a medical record a physician s statement your elementary or secondary school health record or proof of immune titer. Appropriate documentation is required for a medical or religious exemption* If you need further assistance please contact the Dean of Student Services at 203 773-8541. MEASLES/RUBELLA IMMUNIZATION CERTIFICATION INFORMATION SHEET This is to inform you that the Public Act 89 - 90 requires all Connecticut college students born after December 31 1956 provide the Health Office with documentation of adequate immunization against measles and rubella* As a result Albertus Magnus College must take the necessary measures as mandated by the state statue. Adequate immunization according to State Statue MEASLES All new and readmitted students born after December 31 1956 must provide proof of two 2 doses of measles vaccine - one dose administered after January 1 1969 and after the students first birthday. Adequate immunization according to State Statue MEASLES All new and readmitted students born after December 31 1956 must provide proof of two 2 doses of measles vaccine - one dose administered after January 1 1969 and after the students first birthday. The second dose of measles vaccine required to be given at least 30 days after the first dose. RUBELLA German Measles one 1 dose administered after the students first birthday is considered adequate immunization* Students registering at Albertus Magnus College will be required to bring proof of immunization for measles and rubella prior to registration* ANY STUDENT NOT SHOWING THE NECESSARY PROOF OF IMMUNIZATION WILL NOT BE ABLE TO REGISTER* One of the following documents in necessary a medical record a physician s statement your elementary or secondary school health record or proof of immune titer.