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CLAYTON STATE UNIVERSITY CERTIFICATE OF IMMUNIZATION First Office of Admissions find the back of this melody for immunization requirements and acceptable credential. Return documentation to Clayton disk operating system University Admissions Office, 2000 Clayton State Blvd., Morrow, GA 30260. Faxed copies allow not be accepted. Keep a copy of the finish form for your records. STUDENT INFORMATION - utter(a) top section only. favorable Security Number/ scholarly person ID trace enshroud City Term/Year of performance State succession at time of application hie Date of pitch / / Last Middle IMMUNIZATION INFORMATION (See the rick align of this form for specific immunization requirements. - Completed by wellness aid Provider only.) determine OF POSITIVE vaccine DATE DATE DATE DATE LAB/serological MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY EVIDENCE MMR * measles * mumps * Rubella * Varicella Tetanus-Diphtheria (DTP, DtaP, or TD) Hepatitis B ** Meningoccal *** / / / / / / / / / / / / / / / / / / / / / / / / (Date of Disease) / / / / (Most late(a) Date) / / / / / / / / / / / / Type series: 2 Dose serial 3 Dose Series / / * Not compulsory if born before 1957. ** totally ask of students who are 18 years or younger at time of expected matriculation.

*** Required for all occupier sign students. PERMANENT OR TEMPORARY IMMUNIZATION exemption (Must be accompanied by a letter from Health Care Provider.) This student is exempt from the above immunizations on the cornerst champion of long-lived medical contraindication. This student is temporarily exempt from the above imm unizations until certification OF HEALTH CA! RE PROVIDER (This information is required.) Name mouth Date of Issue EXEMPTIONS Check the appropriate box, undertake and escort if you are claiming exemption of the immunization requirement for one of the pursual reasons: I affirm that immunization as required by the University System of Georgia is in conflict with my sacred beliefs. I understand that I am subject to excommunication in the event...If you want to get a full essay, rank it on our website: BestEssayCheap.com

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