College of St. Scholastica
Student Immunization


Return to the Application Checklist

Applicant Information*Required Fields
*Last name:
*First name:
*Middle name:
*SSN:
*Birth date:
Applying for:M.A. B.A.
Program name:
Campus:
Term attending:Fall Spring Summer — 20


Minnesota Law (M.S. 135A.14) requires that all students born after December 31, 1956, and enrolled in a private or public post-secondary school or living in on-campus housing, be immunized against diphtheria, tetanus (Td), measles, mumps and rubella (MMR), with the exception of students who graduated from a Minnesota high school in 1997 or later (because they will have already met the immunization requirements as a high school student). This form is designed to provide the school with the information required by law and will be available for review by the Minnesota Department of Health and the local community health board.



Enter the month, day (if available) and year of the most recent "booster" for diphtheria and tetanus (must be within the past 10 years) and all doses of vaccine for measles, mumps and rubella that were given after 12 months of age.
mm/dd/yyyy mm/dd/yyyy
Diphtheria and Tetanus (Td)
Measles (rubeola, red measles)
Mumps
Rubella (German measles)
*By checking this box, I certify that the above information is a true and accurate statement of the dates on which I received the immunizations required by law.


Exemptions
Students wishing to file an exemption to any of the required immunizations must complete the following:
Medical Exemption: The student named above does not have one or more of the required immunizations because he/she has (check all that apply):
a medical problem that precludes the vaccine(s).
not been immunized because of a history of disease.
laboratory evidence of immunity against
Conscientious Exemption: By checking this box, I hereby certify by notarization that immunization against is contrary to my conscientiously held beliefs.
By law, conscientious exemption statements are forwarded to the Minnesota state commissioner of health.