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Health & Wellness Center | Mandatory Immunization Form

Immunization Record

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.

Required Immunizations

  • 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
  • Varicella Dose 1 and 2 or a History of Chicken Pox
  • Three (3) doses of polio vaccine

Recommended Immunizations

• TB Skin Test

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 healthcenter@trinitydc.edu.

Mandatory Immunization Record Form


For more information contact the Health and Wellness Center at 202-884-9615.

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