Immunization Records Form

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Student Information


MMR (Measles, Mumps, Rubella)

Hepatitis B Series

Meningococcal (required only if living on campus)

Oklahoma law requires all students to provide immunization information or sign a religious/moral exemption. If you can answer “yes” to any of the following questions, you are not required to submit your immunization records.

Moral or Religious Exemption: (Name needed here ONLY if there is an moral/religious exemption.) Please provide the name of the parent or guardian of the above-named person or the person himself/herself who has an adherent moral or religious belief opposed to immunizations. This will serve as your signature for this opposition.

Immunization Records (if applicable)

I hereby state that all of the information given in this document to the best of my knowledge to be true.

 Check this box as your electronic signature.

*In the event of an outbreak, students without proof of immunization may not be allowed to attend class or other group activities.

Northwestern Oklahoma State University

709 Oklahoma Blvd., Alva, OK 73717
Phone: (580) 327-1700

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University. All Rights Reserved.

Mission Statement

Northwestern Oklahoma State University provides quality educational and cultural opportunities to learners with diverse needs by cultivating ethical leadership and service, critical thinking and fiscal responsibility.

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