Austin College Early Scholars 2016 Immunization and Health Form

Austin College Early Scholars 2016 Immunization and Health Form

Student Name: Date of Birth
Immunizations Required for All Students Attending Austin College

Persons seeking an exemption for religious reasons or reasons of conscience need to follow the State of Texas guidelines listed on their website https://webds.dshs.state.tx.us/immco/affidavit.shtm or link from Austin College Health Services site. If exemption is requested for Medical reasons, an affidavit or certificate from your Physician stating the medical risk and which immunizations cause this risk must be submitted including Physician’s signature, and stamp from clinic or office. Records from doctor's office, health departments, or schools will be accepted in lieu of signature below. Make a copy of this record for yourself.

DATE:

(Booster required if 5 yrs ago)

MENINGOCOCCAL (MCV4)

***(Required by Texas State Law, if under 22 years of age)

TETANUS-DIPHTHERIA- PERTUSSIS (Tdap)

(Required within the past 10 years)

Date of Last Booster

M.M.R. (Measles, Mumps, Rubella)

1. Dose 1 - given at twelve (12) months of age or after. ______

2. Dose 2 - given at four (4) years of age or later. ______

(Must have had second dose before coming to Austin College)

POLIO

Completed primary series of polio immunization: q Yes q No

Date of Last Booster

VARICELLA (* not required if has History of Chicken Pox Disease)

1. Dose 1 - given at twelve (12) months of age or after. ______

2. Dose 2 - given at four (4) years of age or later. ______

History of Chicken Pox Disease q Yes q No Year______

TUBERCULOSIS (TB Test) Required Within the Past 1 Year

Check appropriate box. Either of these tests are accepted. TSpot, PPD, or chest X-Ray.

q 1. TSpot – date of test______, results Neg _____ Pos ______.

q 2. PPD (Mantoux) test (Circle One)

Date test given ______Date results read______results in mm/______Neg Pos

q 3. If Positive PPD - chest x-ray required

Give date and result of chest x-ray

Result Month/Day/Year

Hepatitis A (2 dose Series)

First / Second

Not required but recommended: Austin College, the Center for Disease Control, the American College Health Association and the American Academy of Pediatrics highly recommend these additional immunizations:

Hepatitis B (Series)

First / Second / Third

Human Papillomavirus (Gardasil)

First / Second / Third

Health Care Provider Signature:

______Date _____

Disability Accommodations

Austin College provides accommodations in accordance with the Americans with Disabilities Act Amendments Act (ADA-AA) for eligible students. Eligible students must provide documentation that appropriately substantiates the need for requested accommodations with their application materials.

Medical Insurance Verification

Austin College requires all enrolled students to have valid health insurance. You must go online to

http://www2.academichealthplans.com/school/2351.html to enter your current insurance information for verification or provide the information here:

My medical insurance plan is______

Group ______Policy number______

Your scholar may be eligible to remain on your employee insurance plan.

Health Information (you may append additional information)

Does your son/student have any chronic or recurring medical condition which may require medical attention during the ACES program? Yes/No

If Yes please elaborate so that adequate precautions may be made. This information will be kept confidential and only shared with Austin College on a need-to-know basis.

Adjustment to college is a challenge for all students. Students with behavioral/psychological issues may experience more significant adjustment problems. For this reason, college personnel request disclosure of information to promote continuity of care, as well as informed intervention should a crisis occur. All information disclosed on this form will be kept confidential and will be shared with appropriate College personnel on a need-to-know basis only.

Is your son/daughter taking medications which he/she will need to continue during the ACES program? Yes/No.

If Yes, please elaborate. All information disclosed on this form will be kept confidential and will be shared with appropriate College personnel on a need-to-know basis only.