Immunization Record

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

Phone

Street Address

City

State

Zip Code

Immunizations

Must have received after 12 months of age:

Measles (rubeola, red measles)

Month/Year

Mumps

Month/Year

Rubella (German Measles)

Month/Year

Must be within the last 10 years:

Diphtheria & Tetanus (TD)

Month/Year

Student Signature

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