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 Name Last Name

Student ID *

Last 4 digits of SSN

Student Date of Birth *

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? *

Yes No

Signature

Clear