This for must be completed by your health care provider in order to register for classes
The District of Columbia requires that every student who is under the age of 26 at the time of registration be immunized from the following diseases.
- Three (3) doses of DPT in childhood and a booster of Tetanus/Diphtheria (TD) within the last 10 years.
- Two (2) doses of measles/mumps/rubella (MMR) after 12 months of age, at least 1 month apart
- Hepatitis B (3 doses)
- Meningitis Vaccine- 2 doses
- Varicella Two (2) doses or a History of Chicken Pox
- Three (3) doses of polio vaccine
- Tb screening test within the past 12 months
- Hepatitis A
- Human Papilloma Virus (HPV)
Please download the form below and have your medical provider fill out the required information and either hand deliver, Fax (202-884-9614), or Scan and email your form to firstname.lastname@example.org.