GLSP Immunization Compliance Form

GLSP immunization
cover sheet

Wesleyan Student Health Services
327 High Street
Middletown CT 06459
Fax: (860) 685-2471

Connecticut State law requires students registering at post-secondary schools demonstrate that they meet criteria of adequate immunization against measles and rubella. This cover sheet and the immunization documentation should be delivered to the Wesleyan Student Health Services at the address at the top of the page by mail, hand delivery, or fax. You will receive a copy of this form within three weeks to confirm the status of your immunization documentation. Students born on or before January 1, 1957 are exempt.

Personal Information (Student Use):

WesID:	___ ___ ___ ___ ___ ___
Name:	________________________________________________
Address:	________________________________________________
City:	______________	State: ________	Zip: ___________

Documentation provided (Physician or Student Use):

Please provide one of the following types of immunization documentation, checking appropriate box:
	Certified laboratory report showing protection against measles and rubella
	Signed letter from student's physician stating that the student has met State of Connecticut immunization series criteria for higher education, including the dates of the doses
	Physician's note stating that, in physician's opinion, immunization is contraindicated and the specific reason for the opinion
	Signed letter from student's physician or health director in student's present or previous town stating that the student has had a confirmed case of the disease
	Signed affidavit stating immunization is contrary to his or her religious beliefs
	State of CT high school diploma or transcript indicating graduation in 1999 or later
	This cover sheet and the immunization documentation should be delivered to the Wesleyan Student Health Services at the address at the top of the page by mail, hand delivery, or fax.

WESLEYAN UNIVERSITY USE ONLY