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Intensive English Program Immunization Form Last Name First Name Date of Birth Month / Day / Year All students entering Kennesaw State University s Intensive English Program must show proof of immunity to measles mumps rubella varicella chicken pox tetanus diphtheria and pertussis whooping cough. All students 18 years old and younger must show proof of 3 hepatitis B immunizations. Students living in the dorms are required to receive one meningitis immunization* A nurse practitioner or physician must complete and sign the form below. MMR Date of Date of Disease Date of Titer 1 Measles Mumps Rubella Dtap diphtheria tetanus pertussis Varicella Within the last 10 years N/A Hepatitis B 18 younger Meningitis dorm residents Temporary Medical Exemption date it will end Permanent attach explanation Name of Health Care Provider Address of Health Care Provider Phone Number of Health Care Provider Signature of Health Care Provider Date Signed Religious Exemption I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required* Signature only if declaring religious exemption Date Return completed form to Intensive English Program 1000 Chastain Rd. All students 18 years old and younger must show proof of 3 hepatitis B immunizations. Students living in the dorms are required to receive one meningitis immunization* A nurse practitioner or physician must complete and sign the form below. MMR Date of Date of Disease Date of Titer 1 Measles Mumps Rubella Dtap diphtheria tetanus pertussis Varicella Within the last 10 years N/A Hepatitis B 18 younger Meningitis dorm residents Temporary Medical Exemption date it will end Permanent attach explanation Name of Health Care Provider Address of Health Care Provider Phone Number of Health Care Provider Signature of Health Care Provider Date Signed Religious Exemption I affirm that immunizations are in conflict with my religious beliefs. MMR Date of Date of Disease Date of Titer 1 Measles Mumps Rubella Dtap diphtheria tetanus pertussis Varicella Within the last 10 years N/A Hepatitis B 18 younger Meningitis dorm residents Temporary Medical Exemption date it will end Permanent attach explanation Name of Health Care Provider Address of Health Care Provider Phone Number of Health Care Provider Signature of Health Care Provider Date Signed Religious Exemption I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required* Signature only if declaring religious exemption Date Return completed form to Intensive English Program 1000 Chastain Rd. All students 18 years old and younger must show proof of 3 hepatitis B immunizations. Students living in the dorms are required to receive one meningitis immunization* A nurse practitioner or physician must complete and sign the form below. MMR Date of Date of Disease Date of Titer 1 Measles Mumps Rubella Dtap diphtheria tetanus pertussis Varicella Within the last 10 years N/A Hepatitis B 18 younger Meningitis dorm residents Temporary Medical Exemption date it will end Permanent attach explanation Name of Health Care Provider Address of Health Care Provider Phone Number of Health Care Provider Signature of Health Care Provider Date Signed Religious Exemption I affirm that immunizations are in conflict with my religious beliefs. I understand that I may be subject to exclusion from campus in the event of an outbreak of a disease for which immunization is required* Signature only if declaring religious exemption Date Return completed form to Intensive English Program 1000 Chastain Rd.

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