Dear Student:
State Law requires that college students born after January 1, 1957 must present proof of immunity against
Measles, Mumps and Rubella. Failure to comply with this requirement will block your registration and/or make you
ineligible to attend class and may affect financial aid. Immunization forms must be returned no later than two
weeks before your scheduled registration date.
Two doses of live measles vaccine
One dose of live mumps vaccine
One dose of live rubella vaccine
administered on or after January
administered after 12 months of
administered after 12 months of
1, 1968 and 12 months of age,
age and on or after January 1,
age on or after January 1, 1969, or
second dose to be administered at
least 28 days after the first dose,
or physician documentation of
1969, or physician documentation
of mumps disease, or blood test
showing immunity to disease.
a blood test showing immunity to
disease. Note: a history of having
had rubella is not acceptable proof
measles disease, or blood test
showing immunity to disease.
Please complete the student's personal information and have your doctor/clinic fill out all applicable sections below and
return to the Health Services Center (health-center@lagcc.cuny.edu) before registration.
NAME____________________________________________________ Social Security #_______/______/_______
ADDRESS _____________________________________________________ Zip _________________________
PHONE_____________________________ DATE OF BIRTH _______/______/______ Male______ Female_______
PARENT/GUARDIAN NAME ____________________________________ PHONE _________________________
ADDRESS __________________________________________________________________________________
First dose given on or after 1/1/68 and on or after first birthday
First dose given on or after 1/1/69 and on or after first birthday
Second dose given on or after 15 months of age
Date and history of disease
Copy of laboratory report blood test with levels and date
I certify that the above named student has received the above immunizations or has a clinical history or laboratory
evidence of immunity as indicated.
Physician signature /stamp required______________________________________ Date___________________
Address ___________________________________________________________________________________
City, State, Zip ______________________________________________ Phone__________________________
Please return form to Health-Center@lagcc.cuny.edu
