This information is strictly for the use of the University
Health Center and will not be released to anyone without your knowledge and consent.
Please type or print. USE INK
Quarter for which you are applying – Fall/Winter/Spring/Summer: ________________
Name (Mr.) (Mrs.) (Ms.)__________________________________________________________________ Soc. Security #______________
Last First Middle Maiden
Date of birth ______/______/______ Age __________ COUNTRY of birth ______________ Sex _____ Height _____ Weight ________
Present Mailing Address ______________________________________________________________________________________________
Tetanus/Diphtheria combination: Date________________________________________________________________________________________
Information on immunizations must be authenticated by a physician, Public Health Clinic, or transcript from school record. A photocopy of an official immunization record will also be acceptable.
SIGNATURE AND STAMP OF FACILITY___________________________________________________________________________
ADDRESS STREET/PO BOX CITY STATE ZIP CODE
CERTIFICATE OF MEDICAL EXEMPTION
Medical exemption: The above named student is hereby granted a medical exemption on the basis of certain specific health/physical conditions which are recognized contradictions to the administration of required vaccines.
Louisiana state law (Act 1047) requires that all persons who are entering Louisiana colleges and universities for the first time and whose date of birth is after 1956, must submit proof of immunization against preventable and/or communicable diseases, including Measles, Mumps, Rubella, and Tetanus-Diphtheria (MMR, Td).
Louisiana Tech University requires all new students born after December 31, 1956 to provide proof of immunization against MMR and Td. Forms for documenting immunization or establishing an exemption to this requirement are available from the Office of Admissions, Louisiana Tech University, Ruston, LA 71272.
Failure to complete and return these forms will result in the inability to complete the registration process.
REQUEST FOR EXEMPTION – PERSONAL DISSENT
I am requesting exemption from compliance with Louisiana state law (Act 1047) for the following personal reasons: ______________________________________________________________
I understand if I claim exemption for personal or medical reasons, that in the event of an outbreak of measles, mumps, or rubella, I may be excluded from attendance of all campus activities, including classes, until the appropriate disease incubation period has expired or until I submit proof of immunization. If I am not 18 years of age, my parent or legal guardian must sign below.
Student’s signature: __________________________________________________________________________ Date: _____________________________________________________________
Parent or Guardian (if required): _______________________________________________________________ Date: _____________________________________________________________
Please answer all questions. Comment on all positive answers in the space below or on an additional sheet.
Comment on any items checked “Yes” in this Section
A. Are you presently taking any medicine on a regular basis? If so, list.
E. Have you ever been rejected for or discharged from military service or a civilian job because of physical or emotional reasons?
Date of last Injection
Has anyone in your family ever had any of the following:
Cancer, anemia, blood disease
Asthma or Hay Fever
To avoid any delay in registration, please complete and return this form at least four weeks prior to registration. You will not be able to register until this form, including documentation of required immunizations, is complete and on file with the University Health Center.