Rose State College is committed to protecting the health of its students. Therefore, the submission of the
following information is being required of all new students who will be attending classes on campus.
Please check one of the following:
_____ I hereby certify that I have received the vaccinations for measles, mumps, rubella and hepatitis B.
_____ I hereby certify that I have received vaccinations for measles, mumps and rubella and will complete vaccinations for
hepatitis B within six months.
_____ I hereby certify that the administration of the vaccines for measles, mumps, rubella and hepatitis B conflict with my moral
or religious tenets. (In the case of a minor, this must be certified by a parent or legal guardian.)
_____ I am submitting below a physician’s statement indicating it is medically inadvisable for me to take these vaccinations.
_____ I belong to one of the groups of students listed under the exemptions portion of this form, and have identified the group
to which I belong.
The information provided in this document is true and accurate to the best of my ability. I understand that
falsification of this document is a violation of the Student Conduct Code and such conduct could result in
suspension or expulsion from Rose State College.
________________________________________ ________________________________
Student Name Student ID#
________________________________________ ________________________________
Signature of Student, Parent, or Legal Guardian Date
I hereby certify that the administration of the vaccines for measles, mumps, rubella and hepatitis B are medically inadvisable for
the above named student.
________________________________________ ________________________________
Signature of Licensed Physician Date
Certain groups of students will not be asked to provide vaccination information. Please indicate if you belong to any of the
following groups.
_____ I am a high school graduate, and that I graduated from an Oklahoma high school since 1996.
_____ I am transferring from another college located in the State of Oklahoma.
_____ I am only enrolling in off campus or distance education courses.
_____ I am active military.
_____ I am enrolling in Training Center classes only.
_____ I graduated from a high school that required these vaccinations.
State of high school graduation:_____________________Year of graduation: _____________
_____ I have been provisionally admitted and will take no more that 9 credit hours at this institution until I have submitted the
above information and been admitted as a regular student.
If my status at this institution changes so that the above claimed exemption no longer exists, I understand
it is my responsibility to notify the institution of these changes and to provide my vaccination information
before I enroll in additional course.
________________________________________ ________________________________
Student Signature Date
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