Please enter the appropriate dates for your immunization information.

Thank you!

If you have a Medical Exemption or Conscientious Exemption please download this form and mail it back to the Admission Office. Exemption Form

Student ID: (You received your Student Id in your application letter.)

First Name: Last Name: Middle Initial:

Required Immunization Dates

Most recent DT (Diphtheria-Tetanus) within the past 10 years: - 01 02 03 04 05 06 07 08 09 10 11 12 - 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

2 MMRs (Measles, Mumps, Rubella): mm/dd/yyyy mm/dd/yyyy

Recommended Immunization Dates

3 Hepatitis B: mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy

Menactra: mm/dd/yyyy

By submitting this form, I certify that the above dates are accurate information and that I have received the immunizations required by Minnesota State Law (M.S. 135A. 14).