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CERTIFICATE OF IMMUNIZATION Name: Birth Date: Immunizations refused 2026
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- Click ‘Get Form’ to open the Certificate of Immunization in the editor.
- Begin by entering your full name and date of birth in the designated fields at the top of the form.
- Fill in your Student ID number, ensuring accuracy for proper identification.
- In Part I, check the required immunizations you have received. For each vaccine, indicate the doses administered by selecting either a 2-dose or 3-dose series and entering the corresponding dates.
- If you are opting for a waiver for any immunization, make sure to check that option and provide any necessary documentation as indicated.
- Complete Part II regarding Tuberculosis Screening by answering the questions truthfully and providing dates for tests if applicable.
- For exemptions in Part III, select the appropriate exemption type and provide signatures where required. Ensure all information is complete before submission.
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Related links
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This page contains health care provider and staff resources on school and child care immunization requirements and reporting.Read more
Name CERTIFICATE OF IMMUNIZATION Birth Date Immunizations refused because of religious objections. Student checks here, signs and dates the form, and attaches