Immunization Form

Online Certificate of Immunization

All students, undergraduate or graduate, born after January 1, 1957 are required to submit documentation of 2 MMR (Mumps, Measles, Rubella) immunizations or laboratory titer documentation of immunity.  Those students born after January 1, 1980 are required to also submit documentation of 2 chickenpox (varicella) immunizations or evidence of the disease.  These immunizations are required by TN law unless contraindicated by a medical condition or refused due to religious beliefs.  Since all Tennessee public high schools (not home schools) have required proof of MMR and chickenpox (varicella) immunizations, graduation in 1999 or after from a Tennessee public high school (not home school) is considered proof of immunization for MMR but no others. Students who are distance learning-only students or non-degree-seeking students are not required to provide documentation of any of the aforementioned and following immunizations.
Part 1 – Student Information

All items with * are required fields.



 
Part 2 – Immunization documentation

Check the appropriate box(es) below. Graduate students born after 1/1/57 but before 1/1/80 need to only verify MMR immunization and, if born after 1/1/80, need to additionally verify chickenpox (varicella) immunization or evidence of ckickenpox (varicella) disease. All others need to complete the form as applicable. For verification, an OFFICIAL COPY OF THE DOCUMENTATION for items numbered 5-11 below must be faxed to the University Clinic at 615-248-7797. Only the clinic staff has access to this information. If any box numbered 1-6 is checked, no other part of the form needs to be completed.
1. I was born before 1957. If this box is checked, go to the SUBMIT button below.
2. I am a distance learning-only student. If this box is checked, go to the SUBMIT button below.
3. I am a non-degree-seeking student. If this box is checked, go to the SUBMIT button below.
4. I am a graduate of a Tennessee public high school (not home school) in 1999 or after.
5. I have a medical condition that does not allow me to have a MMR or ckickenpox (varicella) immunization. If this box is checked, go to the SUBMIT button below.
6. I claim a religious exemption for immunizations and will submit a written and signed statement faxed to the clinic, affirmed under penalties of perjury, that vaccinations conflict with my religious tenets and practices. If this box is checked, go to the SUBMIT button below.

 7. MMR Vaccine (measles, mumps, rubella)
Fax official documentation to University Clinic. Complete if born after 1/1/1957.


 
 8. Chickenpox (varicella) vaccine
 Fax official documentation to University Clinic. Complete if born after 1/1/1980.


Yes
No

 
 9. Hepatitis B vaccine
Hepatitis B vaccine is suggested for all NEW undergraduate students.
Fax official documentation to University Clinic.





I have read the risks of hepatitis, know that there is an effective vaccine available, and choose not to receive the hepatitis vaccine. A signed waiver, downloaded from the admissions web site, must be submitted. Fax waiver to University Clinic, if declined.

 
All items below with * are required fields for undergraduates.

*10.  Meningitis vaccine OR waiver requirement is limited to freshmen and transfer students who will be living in on-campus housing.
I have read the risks of meningitis, know that there is an effective vaccine available, and choose not to receive the meningitis vaccine. A signed waiver, downloaded from the TNU web site, must be submitted. Fax waiver to University Clinic, if declined.

 

 
 
I certify that the above statements are accurate and complete to the best of my knowledge and that I will fax official documentation as required for verification to the University Clinic (615-248-7797). I understand that withholding information requested in this certificate or giving false information may make me ineligible for admission to or continuation at Trevecca.
Yes No

This confidential information will be sent directly to the University Clinic via the SUBMIT button below. No one will have access to it except the clinic staff.