ADIRONDACK COMMUNITY COLLEGE MENINGOCOCCAL MENINGITIS VACCINATION FORM
New York State Public Law requires that the form below is completed, signed and returned by all students. In accordance with this Law, the College is legally required to maintain a record of your returned response.
Please complete, sign and return this form to the Office of the Dean for Student Affairs.You will not be able to attend classes without this form completed and returned.
Thank you very much for your prompt attention to this very important matter.
MENINGOCOCCAL MENINGITIS VACCINATION REPSONSE FORM
Please respond. A reply is REQUIRED to complete yoru course registration.
Check one (1) box and sign below.
I have/My child has (for students under age 18):
had the meningococaal meningitis immunization (MenomuneTM) within the past 10 years. Date received: __________ read, or have had explained to me, the information regarding meningococcal meningitis disease. I (my child) will obtain immunization against meningococcal meningitis within 30 days from my private health care provider or County Public Health Office. read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease.
Student Signature:________________________________________________________________________
Student's Printed Name:_____________________________________ Student's Date of Birth:____/____/____
Parent/Guardian (if student is a minor):_____________________________ Date:_______________________