Page 36 - VT Student Handbook-Rev 6.12.19_Neat

Murray State College
Veterinary Technology
Student Handbook

From Here… Go Anywhere.

Murray State College Veterinary Technology
Rabies Vaccination Waiver

I have read the material provided and understand that due to my occupational exposure to animals, I
may be at risk of exposure to rabies infection. After reading this material and in consultation with my
physician:

1. I have chosen to have pre-exposure rabies vaccination. The dates the vaccinations were
administered were:
___________________, ____________________, and _____________________.

Please list the name and address of the physician who administered the pre-exposure rabies
vaccination.

Name: __________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Phone: __________________________________________________________

Student Signature: _________________________________________________

OR

2. I decline to undergo pre-exposure rabies prophylactic vaccination.

________________________________________________________________
Name (please print)

__________________________________________ ______________________
Student Signature Date

___________________________________________________

Parent or Guardian Signature (if student is under 18 years of age)

Murray State College  One Murray Campus  Tishomingo, OK 73460  580-387-7000  Fax 580-371-9844 
www.mscok.edu

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