Student #

   


 

Measles Immunity Waiver Form for Students - Summer Session
FRM-U1300.01F
Student Health Center
516 High Street Bellingham, WA 98225-9132
360.650.3400 FAX 360.650.3883


 SUMMER QUARTER ONLY STUDENT

Request for a WAIVER from the Measles Immunity Registration Requirement

 

I did not attend WWU the previous Spring quarter and will not attend WWU the following Fall quarter and request a waiver from the measles immunity requirement as a summer-quarter-only student.

I understand that this waiver is valid only for summer quarter.

I understand that immunity to measles (rubeola) is a condition of continuing my attendance at WWU, if I was born in 1957 or later.  I understand that it is recommended that I prove immunity with the dates for having received two doses of measles vaccine or with a positive rubeola titer (blood test for antibodies).  I understand that approval of this waiver means that if I am exposed to measles, I may be restricted from school from the 5th through the 21st day after exposure or for 7 days after the rash appears.  I have been given an opportunity to ask questions about the vaccine and the policy concerning it.  All my questions have been answered to my satisfaction.

 

Date:      
Student#:

Date of Birth

 
Name:  
 

(Please Print)

 
Signature:  
Current Phone:  
  Fax this form to: Student Health Center, WWU (360) 650-3883

OR

   
  Mail this form to: Student Health Center, WWU
MS 9132
516 High Street
Bellingham, WA 98225-9132
  Questions?: Please e-mail Student.Health@wwu.edu or call (360) 650-7352
     
~Your Registration Hold will be Removed upon Receipt of this Form~