Meningitis Vaccination Waiver

SOUTHWESTERN CHRISTIAN U N I V E R S T Y

Meningococcal disease is a serious, potentially fatal bacterial infection that strikes an average of 1,500 Americans annually. In particular, adolescents and young adults are at increased risk of contracting meningococcal disease. There is a vaccine available that protects against four strains of the disease, which account for approximately 70 percent of cases in the United States. For more information regarding the Meningococcal disease and ways to prevent it please visit the National Meningitis Association website at www.nmaus.org.

Oklahoma Law permits the student or, if the student is a minor, the student's parent or other legal representative, to sign a written waiver stating that he/she has received and reviewed the information provided on the risks associated with meningococcal disease and on the availability and effectiveness of any vaccine, and has chosen not to be or not to have the student vaccinated.
Student's Name (full legal name)*
Student's Date of Birth*

MonthDayYear
Date
Email Address for confirmation copy to be sent to
example@example.com
Entrance Term:*
1) I have received and reviewed information on the risks associated with meningococcal disease.

2) I am aware of the availability and effectiveness of any vaccine (against meningococcal disease

I choose at this time not to be vaccinated against meningococcal disease.
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature: (Required if student is under the age of 18)
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
This form must be filed with the VP of Student Affairs
Should be Empty: