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Mcness e

The document is a proof of immunization compliance form for new students at McNeese, requiring submission of immunization records or requests for waivers. The student, Md Wahidur Zaman, is applying for the Fall 2025 semester and is requesting waivers for measles, mumps, rubella, diphtheria, tetanus, and meningitis on religious grounds. The student acknowledges the potential consequences of not receiving vaccinations and releases the university from any responsibility related to this decision.

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36 views2 pages

Mcness e

The document is a proof of immunization compliance form for new students at McNeese, requiring submission of immunization records or requests for waivers. The student, Md Wahidur Zaman, is applying for the Fall 2025 semester and is requesting waivers for measles, mumps, rubella, diphtheria, tetanus, and meningitis on religious grounds. The student acknowledges the potential consequences of not receiving vaccinations and releases the university from any responsibility related to this decision.

Uploaded by

wahidurzaman.11800988
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Proof of lmmunization Compliance

All students who are attending McNeese for the first time must complete and return this form (Louisiana R.S. 17:170 and R.S. 17:170.1 Schools of Higher
Learning). Additional information regarding immunization requirements may be found here.

The CDC recommends vaccination against COVID-19 and influenza in accordance with their respective schedules.

Student Information
First Name: * Md WAHIDUR Middle Name: Last Name: * ZAMAN

Other/Maiden: Student ID: Date of Birth: (mm/dd/yyyy) * 01/31/1998

lndicate semester and year that you are applying, or have applied, for admission:

Semester: * Fall (August)  Year: * 2025

Immunization Compliance
Are you submitting a copy of your immunization records? * No 
Are you requesting a waiver of the immunization requirements for measles, mumps, rubella, diphtheria, and/or tetanus? * Yes 
Are you requesting a waiver of the immunization requirement for meningitis? * Yes 

Waiver of Vaccination: Measles, Mumps, Rubella, Diphtheria, Tetanus


I request an exemption from the immunization requirement for one or more of the listed diseases: measles, mumps, rubella, diphtheria, tetanus.

The reason for requesting the waiver is: * Religious 

* g
b I understand that I may be required to leave campus and be excluded from classes in the event of an outbreak until the outbreak is over or until I submit proof
c
d
e
f
of immunization.

...3437323930

12/12/2024
Student Signature Date

Waiver of Vaccination: Meningitis


I request an exemption from the immunization requirement for meningitis.

The reason for requesting the waiver is: * Religious 

* g
b I have read and been fully informed by the Centers for Disease Control and Prevention’s Vaccine Information Statement: Meningococcal ACWY Vaccine:
c
d
e
f
What You Need to Know, available at www.cdc.gov. I understand that my health could be negatively affected and my life possibly endangered by not receiving
the vaccine.

I declare myself to be a person of the full age of majority and to be mentally competent. I hereby assume full responsibility for any and all possible present
or future results or complications of my condition as a result of not receiving the vaccination.

I do further hereby now and forever free and release the University and the Department of Health and Hospitals and all its agents, attending health
care professionals, and other personnel from any and all legal or financial responsibility as a result of not receiving the vaccination.

I certify that I have read (or have had read to me) and fully understand this Waiver of Vaccination and Release from Responsibility. All explanations
were made to me and all blanks completed before signing my name. I have elected, of my own free will, not to receive the vaccination.

I understand that I may be required to leave campus and be excluded from classes in the event of an outbreak of any of the listed diseases until the outbreak
is over or until I submit proof of immunization.

...3736373333

12/12/2024
Student Signature Date
Parent Signature Signature not required

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