SHCS Immunizations Verification Submissions

Full Name

Student ID Number

Date of Birth (Month/Day/Year)

Campus Email

Phone Number (If you don't have a U.S. number, leave blank.)

Preferred method of communication (by checking the box below and providing your information, you are providing consent to be contacted via this method)

Email
Phone

Immunization Records You are Uploading to SHCS. Check all that apply:

Measles, Mumps, Rubella (MMR)
Hepatitis B (Hep B)
I am requesting a medical exemption. I have completed the supporting documentation the SHCS website- https://www.csusm.edu/shcs/immunization/index.html
I am requesting a religious / strongly held personal belief exemption. I have completed the supporting documentation from the SHCS website- https://www.csusm.edu/shcs/immunization/index.html

Do you have an immunization hold on your account (MMR or Hepatitis B )?

Yes, I have an MMR immunization hold
Yes, I have Hepatitis B immunization hold
Yes, I have MMR and Hepatitis B immunization hold
No, I do not have a hold on my account

If the document you're providing is for multiple vaccine records, you may attach it once here. If you have multiple documents, you will have the option to attach those on the next page. Please make sure your name is present on the document for verification purposes. If you have an Apple Phone, please make sure that you send as a PDF, PNG or JPG.