Part A - To be completed by the student (please print).
As required under University System Policy, this form must be completed and returned to Darton
before the student will be eligible for enrollemnt.
Expected date of [ ] Fall [ ] Spring
Darton enrollment [ ]Summer 20_______
Name
(last, rst, middle, Jr., III, etc.)
CERTIFICATE OF IMMUNIZATION
COLLEGE
Make a copy of this form to keep with your important papers.
Home Mailing Address
Sex: (optional)
[ ] Male [ ] Female
Date of Birth Social Security Number
Home Physician City, State
REQUIRED IMMUNIZATIONS
I. MMR (Measles, Mumps, Rubella)
____1. Dose 1 - Immunized at 12 months of age or later.
AND (MO/DAY/YR) ____/____/_____
____2. Dose 2 - Immunized at least 30 days after dose 1.
(MO/DAY/YR) ____/____/_____
OR
Measles
____1. Had disease, conrmed by physician diagnosis in ofce record.
OR (MO/YR) ____/_____
____2. Has laboratory evidence of immune titer (specify date of titer).
OR (MO/YR) ____/_____
____3. Immunized with live measles at 12 months of age or later.
AND (MO/DAY/YR) ____/____/_____
____4. Immunized with second dose of live measles vaccine at least 30 days
after rst dose. (MO/DAY/YR) ____/____/_____
Mumps
____1. Had disease, conrmed by physician diagnosis in ofce record.
OR (MO/YR) ____/_____
____2. Has laboratory evidence of immune titer (specify date of titer).
OR (MO/YR) ____/_____
____3. Immunized with live mumps at 12 months of age or later.
(MO/DAY/YR) ____/____/_____
Rubella
____1. Has laboratory evidence of immune titer (specify date of titer).
OR (MO/YR) ____/_____
____2. Immunized with live rubella at 12 months of age or later.
(MO/YR) ____/_____
OR
Exemption
____I was born before 1957, and therefore am exempt from the above
requirement.
II. Tetanus-Diphtheria
_____1. One TD booster dose within the last ten years.
OR (MO/DAY/YR) ____/____/_____
_____2. Completion of primary series (DTaP, DTP or TD) within the past
10 years prior to matriculation.
Completion date (MO/DAY/YR) ____/____/_____
III. Varicella - Note: Required for U.S. students born in 1980 or later.
Required for all foreign born students.
____1. Had disease, conrmed by health care provider.
OR (MO/YR) ____/_____
____2. Has laboratory evidence of immune titer (specify date of titer).
OR (MO/YR) ____/_____
____3. One dose given at 12 months of age or later but before the student’s
13
th
birthday. (MO/DAY/YR) ____/____/_____
OR
____4. Two doses. Dose 1 given after the student’s 13th birthday; second
dose one month after rst dose.
(MO/DAY/YR) 1. ____/____/_____ 2. ____/____/_____
IV. Hepatitis B - Note: Required of all students who are 18 years of age or younger.
(Completion Dates)
____1. Three doses hepatitis B series. (MO/DAY/YR) ____/____/_____
OR
____2. Three doses combined hepatitis A and hepatitis B series.
OR (MO/DAY/YR) ____/____/_____
____3. Two doses of hepatitis B series of Recombivax.
OR (MO/DAY/YR) ____/____/_____
____4. Has laboratory evidence of immune titer (specify date of titer).
(MO/DAY/YR) ____/____/_____
OR
____Over 18 years of age at matriculation.
Immunization status certied by:
________________________________________ _________________
Signature of Health Care Provider Date
___________________________________________________________________
Name of Health Care Provider
___________________________________________________________________
Address of Health Care Provider
Phone (__________) _____________-_________________________
MEDICAL EXEMPTION
_____This student is exempt from the above immunizations on grounds of permanent medical contraindication.
_____This student is exempt from the above immunizations until ____/____/_____. Reason ________________________________________________
_____Religious Exemption: I afrm that immunization as required by The University System of Georgia is in conict with my
religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required.
_____Distance Learning Exemption: I declare that I will be enrolling in ONLY courses offered by distance learning. I understand
that if I register for an on-campus course, this exemption becomes void and I will be excluded from class until I provide proof of
immunization.
__________________________________________________________ ____________________________
Signature of Student Date
Return Form To:
Ofce of Admissions
Darton College
2400 Gillionville Road
Albany, GA 31707-3098
Part B - To be completed and signed by a health care provider.
