One College Drive
Calais, ME 04619
Admissions Office 207-454-1000
Instate: 800-210-6932
Fax: 207-454-1092
Immunization History
Last Name: ___________________________________ First Name: __________________________________ M.I.: _____________
Mailing Address: _______________________________________ City: ______________________ State: _________ Zip: ________
Phone:_______________Mobile Phone:________________Program of Study:______________________Starting Date:___________
Cell phone carrier: US Cellular Verizon AT & T Tracfone Other __________ Text Updates: ___Yes ___No
Email address:________________________________________________Social Security #:____________Date of Birth:__________
In order for you to attend classes at Washington County Community College, you must complete this form and return it BEFORE
YOU CAN BE REGISTERTED FOR CLASSES. Submit the completed form to Enrollment Services.
Maine state law requires that all entering students furnish proof of immunization against measles, mumps, rubella, and diphtheria
/tetanus. Students shall have a physician, nurse or other healthcare professional complete and sign this form or present a copy of an
immunization certificate in its place. The certificate must contain the dates immunizations were given as well as the signature of the
healthcare professional. Students born before January 1, 1957 are exempt from the proof for measles, mumps, and rubella.
TO BE FILLED OUT AND SIGNED BY HEALTHCARE PROFESSIONAL
Required for All Students: Dose #1 Dose #2
MEASLES __/__/__ __/__/__ (RUBEOLA) Two doses of measles vaccine administered after the student was 1 year
old OR results of a TITER test showing immunity. Any child who was immunized prior
to January 1, 1968, with inactivated measles vaccine (Pfizervaz Measles K) must be re-
immunized.
MUMPS __/__/__ __/__/__ Two doses of mumps vaccine administered after the student was 1 year old OR results of
a TITER test showing immunity.
RUBELLA __/__/__ __/__/__ (GERMAN MEASLES) Two doses of Rubella vaccine administered after the student
was 1 year old and after January 1, 1969 OR results of a TITER test showing immunity.
DT, DTP, Tdap, or TD __/__/__ (DIPHTHERIA/TETANUS) Within the last ten years prior to enrollment and by the tenth
Anniversary date while enrolled.
Required for Dorm Residents Only:
MENINGOCOCCAL __/__/__ __/__/__ (MENINGITIS) Two doses for adolescents 11 through 18 years of age: the first dose at
11 or 13 years of age, with a booster dose between ages 16 and 18. If the first dose is
given after the 16
th
birthday, a booster is not needed.
Requirements for Health Programs Only: Not being in compliance prior to enrollment could adversely impact your clinical
placement.
INFLUENZA VACCINATION __/__/__ Annually
HEPATITIS B __/__/__ __/__/__ Series of three required for students enrolled in medical assisting or phlebotomy
programs.
__/__/__
VARICELLA __/__/__ __/__/__ (CHICKENPOX) Two doses required of students in medical assisting & phlebotomy
programs or results of a TITER test showing immunity.
PURE PROTEIN __/__/__ __/__/__ (TUBERCULOSIS) Two-step testing process required of students in medical assisting &
DERIVATIVE phlebotomy programs within 1 year of beginning clinical and annually while enrolled
2-Step positive negative in an allied health program.
Student Signature:________________________________________________________________________Date:________________
Healthcare Professional Signature & Title: _____________________________________________________Date:________________
Non-Discrimination Policy
: Washington County Community College is an equal opportunity/affirmative action institution and employer.
For more information; please call Tatiana Osmond, Affirmative Action Officer, at 454-1094.
AD Form Health History; Revised: July 8, 2019; amd
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