Boarding School Student Immunization Form
Student Information
Student Full Name
Date of Birth
Grade
Parent/Guardian Name
Contact Number
Required Immunizations
Vaccine Name
Date 1st Dose
Date 2nd Dose
Date Booster Dose
Notes
Measles, Mumps, Rubella (MMR)
Diphtheria, Tetanus, Pertussis (DTaP/Tdap)
Polio (IPV/OPV)
Hepatitis B
Varicella (Chickenpox)
Meningococcal
Other
Medical Exemption or Allergies (if any)
Physician Information
Physician Name
Physician Phone
Physician Signature
Date