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NJ CAMPER IMMUNIZATION RECORD
Please complete this Immunization record in full for each camper. The month and year of the immunization must be completed.
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Camper Name
*
Your answer
Which site are you mainly attending in 2023?
*
Hoboken
Montclair
DTaP/DTP or Tdap Completion Date
*
MM
/
DD
/
YYYY
MMR Completion Date
*
MM
/
DD
/
YYYY
Varicella Completion Date
*
MM
/
DD
/
YYYY
Hepatitis B Completion Date
*
MM
/
DD
/
YYYY
Pneumococcal Completion Date
*
MM
/
DD
/
YYYY
Meningococal Completion Date
Ages 11+
MM
/
DD
/
YYYY
Influenza Completion Date
MM
/
DD
/
YYYY
COVID Vaccine Completion Date
MM
/
DD
/
YYYY
Notes:
Your answer
*
This camper is now fully immunized as dated above and may participate in any and all physical and athletic activities without restriction.
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