Immunization Record
(Be sure to keep a copy of this form for your records.)

The State of New Jersey enacted a law in 1995 requiring each full-time student to provide the college with a valid record of immunization verifying two (2) live doses of the MMR (Mumps, Measles and Rubella) vaccine or verification of immunity and three (3) doses of Hepatitis B Vaccine.

If you plan to enroll full-time, submit either your high school health record indicating two (2) lives doses or this form signed by a physician to the Admissions Office prior to the first day of class.

  • If you were born before 1957, you are exempt from this law.
  • If you were born before 1968, you will probably need both live doses of MMR.  Doses are administered one month apart.
  • If you were born after 1968, you may have already received one live dose of MMR and will need an additional live dose.
  • Students not immunized with the (3) doses of Hepatitis B Vaccine series would be permitted up to 9 months to be in compliance.
  Bring or mail the completed form to:
Admissions Office
Mercer County Community College
P. O. Box 17202
Trenton, NJ 08690 USA

Last Name


First Name Middle Initial
Address


City


State Zip Code
Social Security No.


Phone Number Birth Date (Month/Day/Year)
First Enrolled at Mercer (Month/Year)


____ Male    ____ Female

Dates of Live Doses of Vaccines
  1st 2nd 3rd
MMR      
Measles    
Mumps    
Rubella    
Hepatitis B      
OR
Blood Test
  Date
Measles Titer  
Mumps Titer  
Mumps Diagnosis  
Rubella Titer  
Hepatitis B  

Physicianís Signature


Physician's # Date

Exemption
____ I am exempt for medical reasons. Documentation from my physician is attached.
____ I am exempt for religious reasons. Documentation from my religious official is attached.
____ I am exempt because I was born before 1957.

Studentís Signature


Date