Fillable STUDENT COMPLETES Return To:3050 Dr Martin Luther King (Southern University at Shreveport)

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STUDENT COMPLETES Return To:3050 Dr Martin Luther King (Southern University at Shreveport)

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Name: ___________________________________________________ Date of Birth: Month_____Date_____Year_____
SS Number: _______________ — __________ — _______________ Phone #: _________________________________
Gender: Male Female Email: _______________________________
Enrollment Status: Country of Residence: __________________
Permanent Address: ________________________________________________________________________________
City: __________________________________________________ State: _______________ Zip Code: _____________
STUDENT
COMPLETES
Measles, Mumps, Rubella (MMR): #1 Month: __________ Day: __________ Year: __________
#2 Month: __________ Day: __________ Year: __________
Tetanus-Diphtheria-Pertussis (Required within 10 years):
Tdap Month: __________ Day: __________ Year: __________
Td Month: __________ Day: __________ Year: __________
Meningococcal (Required within 5 years):
Menactra Month: __________ Day: __________ Year: __________
or MENVEO Month: __________ Day: __________ Year: __________
HEALTH CARE PROVIDER
Name: _________________________________________ Date: ________________
Signature: ____________________________________________________________
Telephone (Area Code and Number): ______________________________________
PHYSICIAN OR HEALTH DEPARTMENT
COMPLETES
Clinic stamp here:
REQUEST FOR EXEMPTION FROM IMMUNIZATION
Medical Reasons Personal/Religious Reasons
State Reasons:
________________________________________________________________________________________________________
I understand that if I claim excepon I may be excluded from campus and from classes in the event of an outbreak of disease
unl the outbreak is over or I submit proof of immunizaon. If I am not 18 years of age, my legal guardian must sign below.
Student’s Signature: ____________________________________ Parent/Guardian: ____________________________________
PLEASE MAKE A COPY OF THIS DOCUMENT FOR YOUR PERSONAL RECORDS
YOU WILL NOT BE PERMITTED TO REGISTER UNTIL YOU COMPLETE THIS FORM
Return to:3050 Dr Martin Luther King Dr, Shreveport, LA 71107
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STUDENT COMPLETES Return To:3050 Dr Martin Luther King (Southern University at Shreveport)

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Completed 27 July 2020

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