Measles, Mumps & Rubella Immunity Form - Manhattan School of ...

Measles, Mumps & Rubella Immunity FormTO BE COMPLETED BY DOCTOR/CLINIC ONLY. Not valid if student completes form.Return By:• Doctor/Clinic may FAX form with Cover Sheet directly to 212/749-3025• Student may MAIL form to Office of Admissions, Manhattan School of Music, 120 Claremont Ave, NY, NY 10027Student Information Due Wednesday, August 1, 2012________________________________________________________ _________________________________________________________NameInstrument (also indicate whether classical, jazz or contemporary) and Degree_________________________________ _____________________ _________________________________________________________Date of Birth AppID# Social Security NumberImmunity Information (write dates below as month/day/year)Date of Immunization(month/day/year)ORDate of Disease(month/day/year)ORSerologic Evidenceof ImmunityMMR1 st2 ndMeaslesMumpsRubella1 st2 nd OFFICE STAMP HEREClinical diagnosis of rubella disease is notacceptable proof of immunityMUSTATTACHCOPY OFLAB REPORTInformation about these diseases is available at http://www.msmnyc.edu/accepted/immunization.asp.Doctor/Clinic Information___________________________________________________________________________________________________________________Physician SignatureM.D. Registration Number / License Number___________________________________________________________________________________Physician Name (print)___________________________________________________________________________________Address___________________________________________________________________________________City State Zip___________________________________________________________________________________Telephone Number Office Fax Number DateOffice of Admissions, Manhattan School of Music120 Claremont Avenue, New York, NY 10027-4698212-749-2802, ext. 4436 Fax 212-749-3025 www.msmnyc.edu

Meningitis Immunity FormTO BE COMPLETED BY STUDENT OR GUARDIAN. Doctor’s signature is not required.Return by:• FAX to 212-749-3025• SCAN & EMAIL to admission@msmnyc.edu• MAIL to Office of Admissions, 120 Claremont Ave, New York, NY 10027Due Dates:• For SES Students – Due May 1, 2012• For All Others – Due August 1, 2012New York State Public Health Law requires that all college and university students, enrolled for at least six (6) semesterhours or the equivalent per semester, complete this form. If the student is under the age of 18, a legal parent orguardian must complete this form.SELECT A BOX:I have (or my child has) had the meningococcal meningitis immunization (Menomune, MPSV4,Menactra) within the past 10 years.DATE MENINGITIS IMMUNIZATION RECEIVEDMonth: ____________ Day: _____________(Note: Must be received within the last 10 years to be considered valid)Year: ____________________I have (or my child has) read, or have had explained to me, the information regarding meningococcalmeningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) willnot obtain immunization against meningococcal meningitis disease.STUDENT SIGNATURE & INFORMATION(Parent/Guardian should sign for those students who are under 18 years old)__________________________________________________________STUDENT SIGNATURE (or Parent/Guardian for minors)_____________________________________Date___________________________________________________ ___________________________________ __________________________Name (print) Instrument (also indicate whether classical, jazz, or contemporary) Degree Level_______________________________ ___________________ ______________________________ ______________________________Date of Birth AppID# Telephone Number Cell Phone Number___________________________________________________________________________________________________________________E-mail Address___________________________________________________________________________________________________________________Address___________________________________________________________________________________________________________________City State Zip

New York State Public Health Law 2165College Immunization Requirements for Manhattan School of MusicNew York State Health Law 2165 requires college and graduate students born on or after 1 January 1957 to demonstrate proof of immunity againstmeasles, mumps, and rubella. Those born before 1957 do not need to submit proof of immunization. Proof of immunity consists of an officialrecord of immunization or a letter from a doctor on his/her stationery detailing immunization history. All documents must include a signature (not astamp) of the appropriate health official and include dates (month/day/year) of the immunizations.Every student must meet the following requirements before they are allowed to enroll at Manhattan School of MusicMEASLES (Proof of immunity for measles must be shown by meeting one of the following three requirements:)A. Two doses of live measles vaccine (administered after 1967). The first dose must have been received on or after the firstbirthday and the second dose received at or after 15 months of age and at least thirty days after the first dose. Combinedmeasles, mumps and rubella (MMR) is recommended for both doses.B. Physician diagnosis of disease.C. Serologic evidence of immunity.MUMPS (Proof of immunity for mumps must be shown by meeting one of the following three requirements:)A. One dose of live mumps vaccine received on or after the first birthday.B. Physician diagnosis of disease.C. Serologic evidence of immunity.RUBELLA (Proof of immunity for rubella must be shown by meeting one of the following two requirements:)A. One dose of live rubella vaccine received on or after the first birthday.B. Serologic evidence of immunity. Please note: Clinical diagnosis of rubella disease is not acceptable as proof of immunity.EXEMPTIONS1. Persons may be exempt if a physician certifies in writing that the immunizations may be detrimental to their health. Doctormust state when it will be safe for the student to receive the immunizations at a later time.2. Persons who hold genuine and sincere religious beliefs, which are contrary to immunizations, may be exempt after submitting aformal statement to that effect.DISEASE FACT SHEETS (located on the Center for Disease Control Web site)Measles, Mumps & Rubella, please visit: http://www.immunize.org/vis/mmr03.pdfInformation about the disease is also available at http://www.msmnyc.edu/accepted/immunization.asp.QUESTIONS? Please call the Office of Admissions at 212-749-2802 ext. 4436