Meningococcal Meningitis and Hepatitis B

Vaccine Verification/Waiver

 

Florida Statutes requires students who live in an on-campus residence hall to provide documentation of vaccinations against meningococcal meningitis and hepatitis B OR sign a waiver declining the vaccinations.Please complete and return to:
††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Admissions and Records Office

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Chipola College

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† 3094 Indian Circle

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Marianna, Florida 32446-1053

 

 

Student Name _________________________________________________________________

††††††††††††††††††††††† (PRINT)††††††††††† First†††††††††††††††††††††††††††††††††††††††† Middle†††††††††††††††††††††††††††††††††††††††††††††††††††† Last

 

SS# _________________________________†††††††††† Date of Birth ________________________

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Month/Date/Year

 

I have received the required information regarding the risks of acquiring bacterial meningitis and Hepatitis B and the benefits of receiving immunizations to reduce those risks.I also understand that I am required to receive these immunizations or actively decline these immunizations. This form has been truthfully completed to the best of my knowledge and I freely consent to this form being used for my registration at Chipola College or any other college/university.

 

__________________________________††††††††††††††† __________________________________

Studentís Signature††††††††††††††††††††††††††††††††††††††††††††††††††††† Date

 

SECTION A:Immunization Verification - To be completed by medical personnel.

 

Hepatitis B:Dose 1:___________________††††† ††††††††††† Meningococcal Meningitis ___/___/___

†††††††††††††††††††† Dose 2:___________________

†††††††††††††††††††† Dose 3:___________________

 

____________________________†† ___________†† ___________________________________

Physician/Authorized Signature††††††††††††† Date††††††††††††††††††† License # and Office Stamp with Address

 

SECTION B:Vaccine Waiver - To be completed by Student/Parent/Guardian

A separate waiver for each of these vaccines must be signed.

 

____ I decline receiving Menomune vaccine for bacterial meningitis.I acknowledge receipt of

†††††††† information regarding this disease.

 

____ I decline receiving Hepatitis B vaccines.I acknowledge receipt of information regarding this

††††††† disease.

 

_____________________________________††††††††††††††††††††† __________________________________

Studentís Signature††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††† Date

 

REQUIRED AUTHORIZATION FOR STUDENTS UNDER AGE OF 18.I concur with the above:

 

________________________________________††††††††††††††† _____________________________________

Signature of Parent/Guardian††††††††††††††††††††††††††††††††††††††††††††††† †† Date ††††††††††††††††††††††††††††††††††††††††††††††††††† 07/01/03