Student Immunization Form 2026-2027

SAINT VINCENT COLLEGE WELLNESS CENTER

2026 - 2027 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.

This information is strictly for use by Wellness Center staff and will not be released without written student consent.
Student Name*

First NameLast Name
SVC Student ID*
Please enter your Saint Vincent College Student ID number (can be found in your Enrollment Portfolio).
Student Date of Birth*

MonthDayYear
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?*
Please explain:
Are you allergic to any FOOD(S) or ENVIRONMENTAL ALLERGENS?*
Please explain:
Do you have any mental/physical health concerns or diagnosed mental health/medical conditions we should be aware of?*
Please explain:
Required Immunizations:
- MMR (Measles, Mumps, Rubella) series of two doses. The first dose must have been given on or after the student’s first birthday with the second dose being at least four weeks later.
- Meningococcal A (also known as MCV-4, Menveo, Menactra, or MenQuadfi). The first dose is typically given between the ages of 11-12, with a booster dose on or after the student’s sixteenth birthday. If only one dose has been received, it must be on or after the student’s sixteenth birthday.
For the safety of our campus community, students who do not supply proper evidence of immunity or waive their right to immunize using this form may be removed from campus during a communicable disease outbreak in accordance with Pennsylvania state code.
Are you a student who was born or resided outside of the United States? *
In addition to the above immunizations, a tuberculosis (TB) skin test or blood test is required for foreign-born students at high risk for TB.

Students considered to be at high risk for tuberculosis (TB) include those who were born, traveled, or resided in a country with an elevated TB rate for at least a month – this list changes annually but currently includes any country OTHER THAN the United States, Canada, Australia, New Zealand, or a country in western or northern Europe.

Bacille Calmette-Guérin (BCG) is a vaccine for tuberculosis (TB) used in many countries where the disease is endemic. This vaccine is generally not used in the United States and can cause a false-positive TB skin test reaction. Because there is no reliable way to distinguish a positive TB skin test reaction from a reaction caused by the BCG vaccine, the interferon-gamma release assay (IGRA) blood test is the preferred method of testing. An interferon-gamma release assay (IGRA) blood test (also called a QuantiFERON Gold Plus or T-SPOT test) is preferred over a tuberculin skin test for students not born in the United States.

Testing needs to be done within 6 months prior to arriving on campus with results submitted via the upload section at the bottom of this form.
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 on or after your 1st birthday and the second dose at least four weeks later.
1st MMR Date Received

MonthDayYear
Date
2nd MMR Date Received

MonthDayYear
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 most recent administration date.

MonthDayYear
Date
Please direct any questions or concerns to our Wellness Center by email at wellnesscenter@stvincent.edu

Measles, Mumps, Rubella (MMR) Series

Meningococcal ACWY Vaccine