Immunization Waiver

Immunization Waiver
Louisiana law (R.S. 17:170) requires all students to either:

1) Provide proof of immunization for the following:
- two (2) doses of measles vaccine
- one (1) dose of rubella and mumps vaccine
- one (1) tetanus-diphtheria booster (Tdap) dated within 10 years
- one (1) meningococcal vaccine after the age of 16. Two (2) are required if you had your first vaccine prior to the age of 16.
2) Or, you may sign a waiver indicating that you choose not to submit immunization records. By completing this form you are submitting a waiver and will not need to submit immunization records to Goodwill Technical College.
Student Name*

First NameLast Name
Student ID*
Last 4 digits of SSN
Student Date of Birth*

MonthDayYear
Date
Student E-mail*
Waiver Option*

I choose to sign a Proof of Immunization Waiver
By signing below, I acknowledge that I have read and understand the immunization requirements. If I choose to not submit my records I understand that I may be excluded from campus and from classes in the event of an outbreak of measles, mumps, rubella or meningitis until the outbreak is over or until I submit proof of immunization. If I am not 18 years of age, my parent or legal guardian must sign below. I do further hereby, now and forever, free and release Goodwill Technical College and Goodwill Industries of Southeastern LA from any and all legal and financial responsibility as a result of this refusal.
Are you (the student) at least 18 year of age?*

YesNo
Signature

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