Immunization Records Form

(For best results, please fill out this form using the Google Chrome Browser.)

Student Information

First Name *

Middle Name *

Last Name *

Email Address (to receive a copy of this form) *

Date of Birth *

Sex *

Social Security Number *

Date of Entrance to NWOSU *

Status *

Permanent Mailing Address *

City *

State *

Zip Code *

IN CASE OF EMERGENCY, NOTIFY

Emergency Contact's First & Last Name *

Relationship to Student (Parent, Guardian, Next of Kin) *

Phone Number *

Emergency Contact Address *

Emergency Contact City *

Emergency Contact State *

Emergency Contact Zip Code *

MMR (Measles, Mumps, Rubella)

Date of 1st Immunization MMR (month, day, and year) *

Date of 2nd Immunization MMR (month, day, and year) *

Hepatitis B Series

Date of 1st Immunization Hepatitis (month, day, and year) *

Date of 2nd Immunization Hepatitis (month, day, and year) *

Date of 3rd Immunization Hepatitis (month, day, and year) *

Meningococcal (required only if living on campus)

Date of 1st Immunization Meningococcal (month, day, and year)

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.

Did you graduate from an Oklahoma high school after 2002? *

Is your date of birth before 1957? *

I am enrolled only in courses delivered via the Internet or distance learning. (Does not apply if taking classes at the Alva, Enid or Woodward campus) *

I have served in the U.S. Armed Services and have been vaccinated as required by Oklahoma Statute, Title 70 § 3244. *

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.

First & Last Name (Parent, guardian, emancipated student or student 18 years or older)

Current Date

Immunization Records (if applicable)

Upload Records

Terms & Conditions

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.