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Immunization Record
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.
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.
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.
Print and complete this form; bring or mail to:
Admissions Office
Mercer County Community College
P. O. Box B
Trenton, NJ 08690 USA
| Last Name |
First Name |
Middle Initial |
| City |
State |
Zip code |
| Social SecurityNo. |
Phone Number |
Birth Date (Month/Day/Year) |
| First Enrolled at Mercer (Month/Year) |
____ Male
____ Female |
Dates of Live Doses of Vaccines
| |
1st |
2nd |
| MMR |
|
|
| Measles |
|
|
| Mumps |
|
|
| Rubella |
|
|
|
OR |
Blood Test
| |
Date |
| Measles Titer |
|
| Mumps Titer |
|
| Mumps Diagnosis |
|
| Rubella Titer |
|
|
| Physician’s 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.
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