Student Immunization Record (Campus Resident)

This form is to be completed by a medical provider. Incoming students must complete the immunization requirements prior to arriving on campus. If you need assistance with getting immunizations, please contact your local health department or primary care physician. MyHealth Point Park does not provide immunizations. 

Immunization exemption forms can be found on the student health website

** It is recommended to submit your actual immunization records in addition to or instead of this worksheet. PLEASE NOTE: If you submit this form alone as your proof of immunization history, it must be signed or stamped by your medical provider. If this form is submitted without a medical provider's signature or stamp, it will not be accepted. **