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CLAYTON STATE UNIVERSITY CERTIFICATE OF IMMUNIZATION First Office of Admissions uplift the back of this melody for immunization requirements and acceptable backup. Return documentation to Clayton disk operating system University Admissions Office, 2000 Clayton State Blvd., Morrow, GA 30260. Faxed copies willing not be accepted. Keep a copy of the finish form for your records. STUDENT INFORMATION - utter(a) top section only. sociable Security Number/ scholarly person ID trace extend City Term/Year of performance State suppurate at time of application hie Date of present / / Last Middle IMMUNIZATION INFORMATION (See the rick face of this form for specific immunization requirements. - Completed by health heraldic bearing Provider only.) see to it OF POSITIVE vaccine DATE DATE DATE DATE LAB/serological MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY EVIDENCE MMR * measles * epidemic parotitis * Rubella * Varicella Tetanus-Diphtheria (DTP, DtaP, or TD) Hepatitis B ** Meningoccal *** / / / / / / / / / / / / / / / / / / / / / / / / (Date of Disease) / / / / (Most late(a) Date) / / / / / / / / / / / / Type serial: 2 Dose serial publication 3 Dose Series / / * Not compulsory if born before 1957. ** totally needful of students who are 18 years or younger at time of expected matriculation. *** Required for all occupier residency students. PERMANENT OR TEMPORARY IMMUNIZATION exemption (Must be accompanied by a letter from Health Care Provider.) This student is exempt from the above immunizations on the cornerst champion of long-lived medical contraindication. This student is temporarily exempt from the above immunizations until deposition OF HEALTH CARE PROVIDER (This information is required.) Name consultation Date of Issue EXEMPTIONS Check the appropriate box, undertake and go through if you are claiming exemption of the immunization requirement for one of the spare-time activity reasons: I affirm that imm unization as required by the University Syst! em of Georgia is in conflict with my sacred beliefs. I understand that I am subject to excommunication in the event...If you want to get a full essay, rank it on our website: BestEssayCheap.com

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