Proof of Bacterial Meningitis Vaccination

Proof of Bacterial Meningitis Vaccination
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Maiden Name
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TJC Student ID number
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Area CodePhone Number
Email*
example@example.com
Date of Birth*

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Date
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A copy of your official immunization recordExemption documentation
This evidence must be submitted in one of the following formats:

A. A document bearing the signature or stamp of the physician or his/her designee, or public health personnel (must include the month, day, and year the vaccination was administered)

B. An official immunization record generated from a state or local health authority (must include the month, day, and year the vaccination was administered)

C. An official record received from school officials, including a record from another state (must include month, day, and year the vaccination was administered)
A. Exemption for Medical Reasons

An exemption statement signed by a physician who is duly registered and licensed and in good standing to practice medicine in the United States, stating that, in the physician's opinion, the vaccination required would be injurious to the health and well-being of the student.

B. Exemption for Reasons of Conscience

An affidavit signed by the student stating that the student declines the vaccination for bacterial meningitis for reasons of conscience, including a religious belief. A conscientious exemption form from the Texas Department of State Health Services must be used https://corequestjc.dshs.texas.gov/. (Allow up to 30 days)

C. Exclusions for Armed Forces Service Members

To claim an exclusion for armed forces, persons who can prove that they are serving on active duty with the armed forces of the United States are exempted from the requirements in these sections.

Note: Armed forces exclusions apply to active-duty military only. Dependents of service members are NOT excluded from Texas vaccination requirements.
Upload picture (jpg or pdf) of your Bacterial Meningitis Immunization or Exemption documentation*

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