Immunization Temporary Delay Request

Records & Registration
North Hennepin Community College ES 70
Phone: 763-424-0719
Fax: 763-493-0563
Email: registration@nhcc.edu

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Student Information

Last Name

First Name

Student ID/TechID

Street Address

City

State

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Phone

Term And Information

Term

Minnesota Law (M.S. 135A.14) requires that all students born after 1956 and enrolled in a public or private post-secondary school in Minnesota be immunized against diphtheria, tetanus, mumps, and rubella, allowing for certain specified exemptions. This form is designed to provide the school with the information required by the law and will be available for review by the Minnesota Department of Health and the local community health board.

Agreement And Signature

Agreement of Understanding

I understand that this form allows for a temporary delay in meeting the immunization requirement. Immunizations or an exemption must be provided by the 45th calendar day from the start of the term. By failing to provide documentation, I understand an immunization hold will be placed on my account, subsequently hindering my ability to register for courses.

Student's Signature

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