Download Immunization Record Form


New York State Public Health Laws 2165 and 2167 requires all college students enrolled for at least six (6) semester hours per semester or equivalent to provide written proof of:

  • Immunization against Measles, Mumps and Rubella (MMR)
  • Meningococcal Meningitis Vaccination Response

Students must complete all immunization requirements prior to coming to LIM College's campus. The forms must be submitted directly to the Office of Counseling & Accessibility Services no later than one week prior to the first day of classes.

Students may mail the completed forms to the Office of Counseling & Accessibility Services, hand-deliver the forms to the office or may fax the forms to 212-750-3466. Students should retain a copy of all documents submitted to the Office of Counseling & Accessibility Services. 

Regardless of class standing, a student who fails to provide proof prior to 30 days after classes start will be administratively withdrawn from classes and required to vacate campus.


For Measles: Two (2) doses of live vaccine administered on or after your first birthday and after 1967; OR physician documented history of disease; OR serological evidence of immunity

For Mumps: One (1) dose live vaccine administered on or after your first birthday; OR physician documented history of disease; OR serological evidence of immunity

For Rubella (German Measles): One (1) dose live vaccine administered on or after your first birthday; OR serological evidence of immunity. NOTE: Previous diagnosis of Rubella is not acceptable proof.

To be immunized you can go to the Department of Health in the county you reside, or you can call the Office of Counseling & Accessibility Services for a list of walk-in clinics in the New York City area that provide immunization.


Date of vaccination must be provided. Or, you must verify, by your signature on the LIM College Immunization Record form that you’ve received information about Meningococcal disease and have made an informed decision about whether or not to receive immunization against Meningococcal disease. You can comply with this requirement by reading information about meningococcal disease and completing the meningococcal vaccination response section of the LIM College Immunization Record form.



Meningococcal disease is a serious illness, caused by bacteria. It is the leading cause of bacterial meningitis in children 2-18 years old in the United States. Meningitis is an infection of the brain and spinal cord. Meningococcal disease can also cause blood infections. About 2,600 people get meningococcal disease each year in the U.S. 10-15% of these people die despite of treatment with antibiotics. Of those who live, another 11-19% lose their arms or legs, become deaf, have problems with their nervous systems, become mentally retarded, or suffer seizures or strokes. Anyone can get meningococcal disease, but it is most common in infants less than one year of age and people with certain medical conditions, such as lack of a spleen. College freshmen, particularly those who live in dormitories, have a slightly increased risk of getting meningococcal disease.

Meningococcal infections can be treated with drugs such as penicillin. Still, about one out of every 10 people who get the disease dies from it, and many others are affected for life. This is why preventing the disease through use of meningococcal vaccine is important for people at highest risk.

For more detailed information on the meningococcal disease, vaccine, who should get the vaccine and risks of the vaccine, please contact the Centers for Disease Control and Prevention (CDC) at 1-800-232-4636 (1-800-CDC-INFO) or visit CDC’s meningococcal disease website. []



If you were born before Jan. 1, 1957 you are exempt from the Measles, Mumps and Rubella Immunization requirements.


If you hold genuine and sincere religious beliefs which are contrary to the practices of immunization, you may be exempt from these requirements. If you request religious exemption, you will need to submit an explanation in writing. You may be asked to provide additional information or to meet with the Senior Director of Counseling & Accessibility Services for approval of a religious exemption.


You may be granted an exemption to these immunization requirements if a physician has determined that a particular vaccine(s) required is not advisable for you due to medical contraindication. If it’s determined this particular vaccine(s) is no longer contraindicated, you’ll be required to have the vaccine(s). You must submit, in writing, documentation signed by a licensed medical practitioner indicating medical contraindication. The temporary or permanent nature of this exemption shall be noted in the medical documentation.

NOTE: You should understand the consequences of not getting immunized. If there is an outbreak or threat of an outbreak of a vaccine preventable disease, non-immune students may be excluded from campus by an order written by the New York State Department of Health. The order remains in force until the outbreak or the immediate risk of outbreak has ended. It should be noted that extended period of absences from classes can result in academic failure. In such cases that you are not able to attend class due to non-immunization and disease outbreak, LIM College will not be responsible for academic failure and/or tuition costs for the enrolled semester.