Student Health Center Forms

CERTIFICATE OF IMMUNIZATION

The following form may be downloaded and filled out by your Doctor or Health Care Provider, indicating all immunizations you have received and on what date(s).

Link to the Certificate of Immunization

EXEMPTION FORMS

To exempt from receiving MMR vaccines, please submit to the Student Health Center an exemption form Colorado law requires all students attending Colorado schools to be vaccinated against certain diseases unless they have a medical or non-medical exemption on file (Colorado Board of Health rule 6 CCR 1009-2). To protect unvaccinated students, individuals with an exemption from one or more required vaccines may be kept out of a school during a disease outbreak.

Medical exemptions

Students with a complete medical exemption form (signed by a medical doctor, doctor of osteopathic medicine, advanced practice nurse or delegated physician's assistant) need to file this form only once unless the student’s information or school changes.

The link to the Medical exemption: Medical Exemption form

Non-medical (personal belief or religious) exemptions

The link to Non-Medical exemption: Non-Medical exemption form

Once you have completed either exemption form, print it out and upload online to www.fortlewis.edu/shcupload 

OR

Mail to: Student Health Center, 1000 Rim Drive, 170 Skyhawk Station, Durango, CO 81301 

OR

Fax: 970-247-2671

Authorization to Release Health Information from FLC
If you are requesting a copy of your immunization records please attempt to locate your original record before contacting us. If you are unable to obtain your original record you may request a copy from us by submitting the form above via email: hc_immun@fortlewis.edu, fax 970-247-7621. Please allow 3-7 days to process your request. We will scan and email the record back to you and you will be responsible to forward this to the appropriate facility.

Authorization to Release Health Information to FLC
The above form is to request information to be sent from your physician to Fort Lewis College. Fill out this form and email it to hc_immun@fortlewis.edu or fax to 970-247-7621.