Immunization Records Form

(For best results, please fill out this form using the Google Chrome Browser.)

Student Information

First Name *

Middle Name *

Last Name *

Email Address (to receive a copy of this form) *

Date of Birth *

Sex *

Social Security Number *

Date of Entrance to NWOSU *

Status *

Permanent Mailing Address *

City *

State *

Zip Code *

IN CASE OF EMERGENCY, NOTIFY

Emergency Contact's First & Last Name *

Relationship to Student (Parent, Guardian, Next of Kin) *

Phone Number *

Emergency Contact Address *

Emergency Contact City *

Emergency Contact State *

Emergency Contact Zip Code *

MMR (Measles, Mumps, Rubella)

Date of 1st Immunization MMR (month, day, and year) *

Date of 2nd Immunization MMR (month, day, and year) *

Hepatitis B Series

Date of 1st Immunization Hepatitis (month, day, and year) *

Date of 2nd Immunization Hepatitis (month, day, and year) *

Date of 3rd Immunization Hepatitis (month, day, and year) *

Meningococcal (required only if living on campus)

Date of 1st Immunization Meningococcal (month, day, and year)

Oklahoma law requires all students to provide immunization information or sign a religious/moral exemption. If you can answer 鈥測es鈥� to any of the following questions, you are not required to submit your immunization records.

Did you graduate from an Oklahoma high school after 2002? *

Is your date of birth before 1957? *

I am enrolled only in courses delivered via the Internet or distance learning. (Does not apply if taking classes at the Alva, Enid or Woodward campus) *

I have served in the U.S. Armed Services and have been vaccinated as required by Oklahoma Statute, Title 70 搂 3244. *

Moral or Religious Exemption: (Name needed here ONLY if there is an moral/religious exemption.) Please provide the name of the parent or guardian of the above-named person or the person himself/herself who has an adherent moral or religious belief opposed to immunizations. This will serve as your signature for this opposition.

First & Last Name (Parent, guardian, emancipated student or student 18 years or older)

Current Date

Immunization Records (if applicable)

Upload Records

Terms & Conditions

I hereby state that all of the information given in this document to the best of my knowledge to be true.

Check this box as your electronic signature.

*In the event of an outbreak, students without proof of immunization may not be allowed to attend class or other group activities.

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