1004880864_43777 1_2

Rev 11/18/20

Entering Student Immunization Form

Submit this completed form, signed and stamped by a licensed medical provider, at
secure.magnushealthportal.com.

I am a student at (check one): ___ Berklee College of Music ___ Boston Conservatory at Berklee

Program (check all that apply): ___ Undergraduate ___ Graduate ___ MEIP ___ First Year Abroad

Instructions
A physician must complete the immunization dates on this form in month/day/year format with a signature and
stamp. All students must submit the completed immunization records required by the Commonwealth of
Massachusetts in order to matriculate. Please note: Students cannot attend Berklee College of Music or Boston
Conservatory at Berklee unless these requirements are met.

*These requirements shall not apply where:

1. the student meets the standards for medical or religious exemption set forth in M.G.L c. 76, s15c.; or
2. the student provides a copy of a completed immunization record from a school indicating the receipt in
the case of the meningococcal requirement, the student, or the student’s parent or guardian if the
student is a minor, signs the meningococcal waiver approved by the Department of Public Health stating
that the student has received information about the risks and dangers of meningococcal disease, has
reviewed the information provided, and has elected to decline the vaccine.
*Please submit the following supporting evidence with this form if any of the above exemptions apply.
1. Religious exemptions: The student must contact the Health and Wellness Department by phone or
email to obtain a copy of our exemption form. The signed exemption form must be sent to Magnus
Health along with this immunization form and received prior to the student’s arrival on campus. The
exemption will need to be renewed every school year.
2. Medical exemptions: The student must contact the Health and Wellness Department by phone or email
to obtain a copy of our exemption form. The signed exemption form must be sent to Magnus Health
along with this immunization form and a letter from a medical provider that specifies which
immunization(s) cannot be given and the condition that prevents the administration of the vaccine.
These documents must be received prior to the student’s arrival on campus. The exemption will need
to be renewed every school year.
3. Meningococcal waiver: The student must provide the signed, approved meningococcal waiver form
provided by the Department of Public Health once the student has carefully read the risks of meningococcal
disease.

Please submit a copy of this form along with any supporting documents online at
secure.magnushealthportal.com.

Magnus Help Desk Number: 877-461-6831, or for callers outside of the U.S.: 919-502-7689
Magnus Help Desk Email: service@magnushealthportal.com

SEE REVERSE SIDE OF FORM FOR IMMUNIZATION DOCUMENTATION

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Student Last/Family Name Date of Birth Student ID #

Vaccine D ate( s) M assachusetts State R equirem ent
Two-dose series (measles, mumps, and rubella)
MMR #1 / / #2 / / Minimum of four weeks apart, with first
Month Day Year Month Day Year dose at least one year after birth
OR OR
Measles #1 / / #2 / / Two-dose series
(Two-dose Month Day Year Month Day Year Minimum of four weeks apart, with first
series) dose at least one year after birth
Mumps #1 / / #2 / / Two-dose series
(Two-dose Month Day Year Month Day Year Minimum of four weeks apart, with first
series) dose at least one year after birth
Rubella #1 / / #2 / / Two-dose series
(Two-dose Month Day Year Month Day Year Minimum of four weeks apart, with first
series) dose at least one year after birth
OR OR
Measles (titer) Positive titer: / /
Month Day Year
Mumps (titer) Positive titer: / / Positive titer tests proving
Month Day Year
immunity to all three
Rubella (titer) Positive titer: / /
Month Day Year
Tdap Only Tdap is acceptable.
(Tetanus,
/ / No other form of tetanus shot is accepted. Td
Diphtheria,
and Pertussis) Month Day Year
should be given if it has been ≥10 years since Tdap.

Hepatitis B Three-dose series

#1 / / #2 / / #3 / /
(Three-dose Two doses of Heplisav-B given on or
series) Month Day Year Month Day Year Month Day Year after 18 years of age are acceptable.
OR OR

Hepatitis B Positive titer test proving immunity

/ /
(titer) Positive titer:
Month Day Year

Two-dose series
#1 / / #2 / /
Varicella Month Day Year Month Day Year
Minimum of four weeks apart
First dose at least one year after birth
OR OR
Varicella Positive titer: / / Positive titer test proving immunity
(titer) Month Day Year
OR OR

Date of disease: / / History of disease

Chicken Pox
Month Day Year Must be verified by a medical provider

Only MenACWY or MCV4 is acceptable.

Meningococcal
/ / No other form of the meningococcal vaccine
(MenACWY Month Day Year is accepted.
Formerly This is required if you’re 21 years of age and
MCV4) younger (<22 years of age), and must be received
on or after the 16th birthday.
Seasonal influenza vaccine for the current flu
season (July–June) must be received
/ / annually by December 31. New students
Influenza (flu) entering between January 1 and March 31
Month Day Year
must have received a dose of the vaccine for
the current flu season for entry.

Physician’s Signature: Date: Stamp (required):