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

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 1-4 below must be faxed to the University Clinic at 615-248-7797. Only the clinic staff has access to this information.

1. MMR Vaccine (measles, mumps, rubella)

Fax official documentation to University Clinic. Complete if born after 1/1/1957.

2. Chickenpox (varicella) vaccine

Fax official documentation to University Clinic. Complete if born after 1/1/1980.

I have had the chickenpox disease OR was born after 1979.

3. Hepatitis B vaccine

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

All items below with * are required fields for undergraduates.

*4. Meningitis vaccine OR waiver requirement is limited to freshmen and transfer students who will be living in on-campus housing.

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.

I understand and agree*

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.