Consent and Immunizations Form

Consent and Immunizations Form DUE November 20.

To complete the Form: 

  1. Download/print the Consent and Immunization  Form:
       for US Citizens
      for F1/J1 VISA Citizens​.​​​​​​
  2. Read and complete the top section.
  3. Have a health care provider complete the lower portion with medical and immunization history on this form.  NO physical is required.

CT Law requires all matriculated college students to be vaccinated against: 

    • Measles, Mumps and Rubella (2 doses of each, all doses after age 1)
    • Neisseria Meningitis (a quadravalent A, C, Y, W-135)dose after age 16
    • Varicella (Chicken Pox) 2 doses, or physician documentation of disease or blood serology proving immunity.

To read information from the Centers for Disease Control (CDC) concerning recommendations for adolescent vaccinations, click here.

For students with documents from a country other than the United States this document may help with interpreting these shots in your own language.

Return the Consent and Immunizations Form to: 
​​     Trinity College Health Center
     300 Summit St.
     Hartford, CT 06106

fax: 860-297-2020

Please contact us​ if you have any questions or if you need to request an extension.