Student Immunization Form
Immunization Forms are due by August 15th. Your submission MUST be received before you may move into a Residence Hall and/or attend classes. ALL students need to complete this form, including student athletes who are also submitting a physical form to the Athletic Department.
Saint Vincent College Wellness Center
This information is strictly for use by Wellness Center staff and will not be released without student consent.
Student Name
*
First Name
Last Name
SVC Student ID
*
Please enter Student ID number.
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Cell Phone Number
*
Please enter a valid cell phone number for the student.
Are you allergic to anything, including medications? If NO, please enter "N/A" and if YES, please explain and include reaction:
*
Do you have any mental/physical health concerns or diagnosed mental health/medical conditions we should be aware of? If NO, please enter "N/A" and if YES, please explain:
*
VACCINATION STATEMENT:
*
My vaccination record information is included below:
I waive the right to vaccinate for religious reasons.
I waive the right to vaccinate for medical reasons.
Required Immunizations: Two MMR (Measles, Mumps, Rubella) Vaccinations and a Meningitis ACWY Vaccine
(up to date meningococcal vaccination is a minimum of one dose administered at age 16 or older and is required by Pennsylvania state code for all incoming students residing on campus)
Measles, Mumps, Rubella (MMR) Series
Two vaccinations REQUIRED by Pennsylvania law
1st MMR Date Received
-
Month
-
Day
Year
Date
2nd MMR Date Received
-
Month
-
Day
Year
Date
Meningococcal ACWY Vaccine
(This is NOT the Meningitis B Vaccine, it may be listed at MCV-4, Menveo, Menactra, or MenQuadfi on your immunization documentation)
Meningococcal ACWY Date Received (REQUIRED to be on or after student's 16th birthday)
-
Month
-
Day
Year
Date
Please direct any questions or concerns to our Wellness Center by email at wellnesscenter@stvincent.edu
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This form must be received by August 15th.
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