Tarrant
County
College
Bacterial Meningitis Vaccination Verification Form
(For New and Returning Students Under the Age of 22)
Student Name: TCC ID:
Home Addre
ss:
@my.tccd.edu
Telephone #: TCC E-mail:
Please read and select the section that applies. Sign, date and submit to your Admissions and Registrar’s Office.
☐ I have received the Bacterial Meningitis vaccine and attached an official vaccination record.
☐ My physician or health care professional has documented my meningococcal vaccine at the bottom of this form.
• I understand the vaccination must be administered at least 10 days prior to the start of classes.
• I understand proof of the vaccination must include the physician or health care professional’s signature, the date the
vaccination was administered, the medical facility’s stamp or seal and contact information.
• I understand I will not be allowed to register for courses at TCC without the meningococcal vaccine.
Student Signature: Date:
*************************************************************************************************************
Vaccine Verification and Medical Facility Information (Completed by Physician/Health Professional)
Name of Administering Medical Facility: ____________________________________________________________________________
Address: ______________________________________________________________ Phone: _________________________________
Name of Administering/Verifying physician or health professional: _______________________________________________________
Type of Vaccination: MCV4 MPSV4 MenB Other ______________________________________
Date meningitis vaccination was administered: _______________________________________________________________________
Note: Vaccine must be proven effective against Bacterial Meningitis and must be approved by the Center for Disease
Control (CDC). Please visit: https://www.cdc.gov/vaccines/vpd/mening/index.html
I hereby verify/confirm the above named student received the mandated Bacterial Meningitis vaccine as required, and the
information provided on this form is true and accurate.
Signature of physician/health care provider: Date:
https://www.tccd.edu/admission/meningitis-vaccinations/
Place Official Stamp Here
Tarrant County College is an Equal Opportunity
institution/equal access to the disabled.
