<%@ Page Language="vb" EnableViewState="true" EnableSessionState="true" CodeBehind="loadForm.vb" Inherits="eSignProcess.loadForm"%> Measles Immunity Report for Student


Student #



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


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 of Birth


(Please Print)

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


  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~