Alvin Community College
Evidence of Vaccination against Bacterial Meningitis
Purpose of Form: This form may be used by any student who is required to satisfy the requirement to submit
evidence of a bacterial meningitis vaccination in compliance with Texas Education Code 51.9191/51.9192
et seq.
and THECB Rule 21.610
et seq.
How to Submit Evidence of Vaccination: Attach official documentation in addition to this form, if
available.
In person: Alvin Community College Admissions Office, A100
Fax: 281-756-5812
Email: Record scanned and emailed to: admissions@alvincollege.edu
SECTION A. This section must be completed by the student.
Student Name: ________________________________________________________
Student ID: _________________________ Date of Birth: _______ / ______ / ______
First Semester at Alvin Community College (Select one and indicate the appropriate year):
□ Fall, Year: __________ □ Spring, Year: __________ □ Summer, Year: ___________
I certify that the information provided is true and accurate. I acknowledge receiving information
from the college about the bacterial meningitis vaccination requirement. The vaccination or booster
is not more than 5 years old as of the first day of the term in which I plan to enroll.
Student Signature: _____________________________________________Date ____ /____ / ____
SECTION B. This section must be completed by a licensed Health Practitioner or Designee.
Vaccine administered: □ MCV-4 (Menactra) □ MPSV-4 (Menomune or Menveo)
Name of the Health Practitioner who administered the vaccination:
_______________________________________________________________
Date of the administration of the bacterial meningitis vaccination: _______ / ______ / ______
Name of the vaccination recipient ______________________________________________
Date of birth of the vaccination recipient ______ / _______ / ________
By signing this form, I certify that the information provided is true and accurate:
・ I am a Health Practitioner authorized by law to administer an immunization or I have legal designation to complete and sign
this form on behalf of a Health Practitioner authorized by law to administer an immunization.
・ The individual who administered the bacterial meningitis vaccination to the student named above is or was a Health
Practitioner authorized by law to administer an immunization.
・ The bacterial meningitis vaccination was administered to the student named above by the Health Practitioner named above
and on the date provided above.
Health Practitioner or Designee Signature: ________________________________ Date _____________
License Number: ________________________________ Phone: _______________________________
2/2019
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