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Student s Signature - REQUIRED MINORS Student under 18 years of age Signature of Parent or Legal Guardian REQUIRED if student is under 18 years of age Printed Name of Parent or Legal Guardian Relationship to Student OFFICE USE ONLY Document Date Received Approved Denied Incomplete By Emailed PS By Log By Return completed form and appropriate documentation to the Office of Admissions via fax 361-580-5500 or email admissions uhv.edu Make a copy of your immunization documentation for your records. Office of Admissions Fax 361. 580. 5500 admissions uhv.edu Bacterial Meningitis Immunization Record Form Please read the Bacterial Meningitis immunization information prior to completing this form. ALL applicable sections should be completed ONLINE prior to printing. STUDENT INFORMATION University of Houston-Victoria ID myUHV ID Date of Birth MM/DD/YYYY Enrollment Term Semester and Year Select Enrollment Term Last Name First Name MI Gender Male Mailing Address Apartment City State Zip Code Female Phone Number Email Address SELECT OPTION 1 OR 2 OPTION 1 Select type of attachment A COPY of your official immunization record signed by a Health Care Provider Date of Immunization MM/DD/YYYY Documentation must be in English Medical Exemption Letter or Certificate Must be signed by a healthcare professional and specify timeframe of exemption Texas Department of State Health Services Conscientious Exemption Form Submit ORIGINAL only a copy will not be accepted An official record received from school officials including a record from another state OPTION 2 To be completed by a Health Care Provider Office Stamp Health Care Provider s Name Address Phone Number Vaccine Administered MCV4 MPSV4 Signature and Title of Health Care Provider Date Vaccine Information Statement I have read and understand the Bacterial Meningitis Immunizations requirements. Office of Admissions Fax 361. 580. 5500 admissions uhv*edu Bacterial Meningitis Immunization Record Form Please read the Bacterial Meningitis immunization information prior to completing this form* ALL applicable sections should be completed ONLINE prior to printing. STUDENT INFORMATION University of Houston-Victoria ID myUHV ID Date of Birth MM/DD/YYYY Enrollment Term Semester and Year Select Enrollment Term Last Name First Name MI Gender Male Mailing Address Apartment City State Zip Code Female Phone Number Email Address SELECT OPTION 1 OR 2 OPTION 1 Select type of attachment A COPY of your official immunization record signed by a Health Care Provider Date of Immunization MM/DD/YYYY Documentation must be in English Medical Exemption Letter or Certificate Must be signed by a healthcare professional and specify timeframe of exemption Texas Department of State Health Services Conscientious Exemption Form Submit ORIGINAL only a copy will not be accepted An official record received from school officials including a record from another state OPTION 2 To be completed by a Health Care Provider Office Stamp Health Care Provider s Name Address Phone Number Vaccine Administered MCV4 MPSV4 Signature and Title of Health Care Provider Date Vaccine Information Statement I have read and understand the Bacterial Meningitis Immunizations requirements.

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