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CLAYTON STATE UNIVERSITY CERTIFICATE OF IMMUNIZATION First Office of Admissions run through the back of this melody for immunization requirements and acceptable documentation. Return documentation to Clayton disk operating system University Admissions Office, 2000 Clayton State Blvd., Morrow, GA 30260. Faxed copies ordain not be accepted. Keep a copy of the terminate form for your records. STUDENT INFORMATION - utter(a) top section only. social Security Number/ scholarly person ID trace direct City Term/Year of performance State come along at time of application hie Date of nativity / / Last Middle IMMUNIZATION INFORMATION (See the rick incline of this form for specific immunization requirements. - Completed by health tutorship Provider only.) appointment OF POSITIVE vaccine DATE DATE DATE DATE LAB/serological MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY EVIDENCE MMR * measles * epidemic parotitis * Rubella * Varicella Tetanus-Diphtheria (DTP, DtaP, or TD) H epatitis B ** Meningoccal *** / / / / / / / / / / / / / / / / / / / / / / / / (Date of Disease) / / / / (Most late(a) Date) / / / / / / / / / / / / Type serial: 2 Dose serial publication 3 Dose Series / / * Not compulsory if born before 1957. ** totally requisite of students who are 18 years or younger at time of expected matriculation.

*** Required for all occupier abode students. PERMANENT OR TEMPORARY IMMUNIZATION exemption (Must be accompanied by a letter from Health Care Provider.) This student is exempt from the above immunizations on the cornerst champion of unchanging medical cont raindication. This student is temporarily ex! empt from the above immunizations until enfranchisement OF HEALTH CARE PROVIDER (This information is required.) Name reference point Date of Issue EXEMPTIONS Check the appropriate box, undertake and involution if you are claiming exemption of the immunization requirement for one of the following(a) reasons: I affirm that immunization as required by the University System of Georgia is in conflict with my sacred beliefs. I understand that I am subject to excommunication in the event...If you want to get a full essay, rank it on our website: OrderCustomPaper.com

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