Bacterial Meningitis Vaccination Verification Form
Last Name First Name HCC Student ID Number
Date of Birth Daytime phone # Email address
I am submitting meningitis immunization documentation as required
I am submitting Medical Exemption affidavit or certificate (Signed statement by physician
stating that the vaccine poses a significant risk to your health. Unless statement indicates
permanent condition, the exemption statement is valid for only one year from the date signed
by the physician)
I am submitting an Affidavit for Exemption from Immunization for Bacterial Meningitis for Reasons
of Conscience.
VERIFICATION FORM & DOCUMENTATION MAY BE SUBMITTED:
• AT ANY CAMPUS
• BY EMAIL: Scan your documentation and attach it to an email sent to vaccine@hccs.edu
• BY FAX: 713/718-2882
• BY U.S. MAIL:
Houston Community College
Admissions & Records,
P.O. Box 667517
Houston, Texas 77266-7517
I have read and understand the Bacterial Meningitis immunization requirement. I certify that the
information I have provided is true and correct.
Student Signature Date
click to sign
signature
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