CERTIFICATE OF IMMUNIZATION - Middle Georgia State …

(MGA 04-Dec-15 - PG 1 of 2) 100 university Parkway, Macon, GA 31206 CERTIFICATE OF IMMUNIZATION Return documentation to Middle Georgia State university . Retain a copy of the completed form for your records. S T U D E N T I N F O R M A T I O N Social Security Number/Student ID: - - Name: (Last) (First) ( Middle ) Address: City: State : Country: Zip Code: Term/Year of Application: Age at time of application: Date of Birth: / / R E Q U I R E D I M M U N I Z A T I O N I N F O R M A T I O N (See the IMMUNIZATION Requirements & Recommendations for USG Students documentation) V A C C I N E D A T E M M / D D / Y Y Y Y D A T E M M / D D / Y Y Y Y D A T E M M / D D / Y Y Y Y H I S T O R Y D A T E O F P O S I T I V E L A B / S E R O L O G I C E V I D E N C E MMR 1 / / / / Measles 1 / / / / / / Mumps 1 / / / / / / Rubella 1 / / / / / / Varicella 3 / / / / (or history of Varicella) / / Tetanus

(MGA – 04-Dec-15 - PG 2 of 2) IMMUNIZATION REQUIREMENTS According to the policies of the Board of Regents of the University System of Georgia, applicants who have not previously attended Middle Georgia State University must

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