University of North Texas
Bacterial Meningitis Immunization Record
STUDENT INFORMATION
UNTD Student ID #
Enrollment Term (Check One)
Fall
Spring
Summer: 3 Week/5 Week 1/10 Week
Summer: 5 Week 2
Year
Last Name
First Name
MI
Mailing Address
Apartment #
Daytime Phone #
( )
-
City
State
Zip Code
Date of Birth
/
/
Age
Email Address
OPTION 1: Select type of attachment (Documentation must be in English or accompanied by a notarized translation.)
Official copy of immunization record stating the type of vaccine administered and signed by a Health Care
Provider
Medical Exemption affidavit or certificate
Texas Department of State Health Services Conscientious Exemption form
Official immunization records generated by a state or local health authority
Official immunization record received from school officials, including a record from another state
OPTION 2: To be completed by a Health Care Provider - USE BLACK INK
Date of Immunization (See paragraph 3 of page 1)
Vaccine Administered
MCV4/Menactra
MPSV4/Menomune
/ /
Official Stamp: Health Care Provider’s Name, Address, Phone Number
Signature and Title of Health Care Provider
Date
/ /
Student’s Signature (18 years of Age or Older) – USE BLACK INK ONLY
Date
/ /
MINORS: Students under 18 Years of Age
Signature of Parent or Guardian– USE BLACK INK ONLY
Date
/ /
Full Name of Parent or Legal Guardian Relationship to Student
I have read and understand the Bacterial Meningitis immunizations requirements. I certify that, to the best of my
knowledge, the above information (including any attached copies) is true and correct. I also give my consent for
the above immunization record to be entered into my electronic student record. I authorize UNTD to communicate
with me regarding my bacterial meningitis immunization requirements via electronic communication or by phone.
Office Use Only
Date Received
/ /
Accepted
Denied
Incomplete
Date Completed / /
Completed By
Please read the immunization requirements prior to completing this form. All applicable sections should be
completed online prior to printing.
SELECTION OPTION 1 OR 2
PLEASE COMPLETE ONE OF THE FOLLOWING TWO OPTIONS
