meningococcal-vaccination-response

Health Services

4513 Manhattan College Pkwy
Horan Room 218
Riverdale, NY 10471
Phone: 718-862-7217 | Fax: 718-862-7797 | Email: health.services@manhattan.edu

Meningococcal Vaccination Response Form

Name*

First Name

Last Name

Date of Birth*

Student ID#*

Cell Phone*

International students please enter the office phone 718-862-7217

Choose one*

Undergrad Grad SCPS

Resident or Commuter*

Resident Commuter Disabled

New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return the following form to Health Services.

Choose one and sign below.

I have / My child has:*

had meningococcal immunization within the past 5 years. The vaccine is recorded on the Immunization form.* (Recommended for Residents) [Note: The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years should have at least 1 dose of Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on or after their 16 th birthday, and that young adults aged 16 through 23 years may choose to receive the Meningococcal B vaccine series. College and university students should discuss the Meningococcal B vaccine with a healthcare provider.] read, or have had explained to me, the information regarding meningococcal disease. I (my child) will obtain immunization against meningococcal disease within 30 days from my private health care provider. read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal disease.

Signature of Student or Parent/Guardian if student is a minor*

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Use your mouse or finger to draw your signature above