2025 - 2026 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 written student consent.
Student Name
*
First Name
Last Name
SVC Student ID
*
Please enter your Saint Vincent College Student ID number.
Student Date of Birth
*
-
Month
-
Day
Year
DOB
Student Cell Phone Number
*
Please enter a valid cell phone number in case we need to contact you by phone.
Are you allergic to any MEDICATIONS? If NO, please enter "N/A" and if YES, please explain and include reaction:
*
Are you allergic to any FOODS OR ENVIRONMENTAL ALLERGENS? 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:
*
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) I understand that if I choose to waive my right to vaccination OR the Wellness Center does not have record of my up-to-date vaccinations, I may be asked to leave my campus housing if there is a suspected/confirmed case of Measles or Meningitis.
VACCINATION STATEMENT:
*
My vaccination record information is included below (please enter dates):
I WAIVE THE RIGHT TO VACCINATE FOR RELIGIOUS REASONS.
I WAIVE THE RIGHT TO VACCINATE FOR MEDICAL REASONS.
Measles, Mumps, Rubella (MMR) Series
Two doses: first dose administered after 12 months of age and the second dose at least month later.
1st MMR Date Received
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Month
-
Day
Year
Date
2nd MMR Date Received
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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 - if you have received two doses, please enter the most recent administration date.
Meningococcal ACWY Date Received (REQUIRED to be on or after student's 16th birthday). If you have received two doses, please enter the date of the most recent dose administered.
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Month
-
Day
Year
Date
Please direct any questions or concerns to our Wellness Center by email at wellnesscenter@stvincent.edu
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Please be sure to click the submit button. Once it has been submitted, it will need to be reviewed by the Wellness Center nurse prior to being marked as "completed" on your Enrollment Portfolio. Please do not submit duplicate entries. Any questions or concerns can be directed to wellnesscenter@stvincent.edu
This form must be received by August 15th.
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