3050 Martin Luther King Jr. Drive
Shreveport, Louisiana 71107
IMMUNIZATION FORM
(Please print using dark ink)
Name: _______________________________________________________________________________
Last First Middle
Last 4-digits of Social Security Number: XXX-XX- Date: _________________
PHYSICIAN MUST COMPLETE THIS SECTION
and
2
nd
Immunization: ___
or
Date of Disease: _____
or
Serologic Test: ____
and
Result: __________
or
Date of Disease: _____
or
Serologic Test: ______
Pertussis: ________
(Date within 10 yrs.)
Meningococcal disease
___________________________________ _____________ ____________________________
Signature of physician/health care provider Date Place address or stamp above
REQUEST FOR EXEMPTION
If you request exemption for medical or personal reasons, please check the appropriate blank and provide the
requested information.
____ Medical reasons: (Attach Physician’s Statement or use space below)
____ Personal reasons: (State reason in space below)
** I understand that if I claim exemption for personal or medical reasons, I may be excluded from campus and
from classes in the event of an outbreak of measles, mumps, rubella, or meningitis until the outbreak is over or
until I submit proof of immunization. If I am not 18 years of age, my parent or legal guardian must sign.
_______________________________ ______________ _________________________ ____________
Student’s Signature Date Parent/Guardian Signature Date
ADM: Immunization Form: Revised 02/14:AM
