Meningococcal Vaccination Waiver Form printable pdf download

TRUMAN STATE UNIVERSITY STUDENT HEALTH CENTER

MENINGOCOCCAL VACCINATION

WAIVER FORM

Name: ________________________________________________________________ Date of Birth:________________________

LAST

FIRST

MM/DD/YYYY

BANNER (Student ID): ____________________________________________ Home/Cell Phone: (______) _____________________

Medical Exemption

Missouri State Law 754 section 174.335 requires all students who reside in on-campus housing at a public institution of

higher education to have received the meningococcal vaccine unless a signed statement of medical or religious exemption

is on ﬁle with the institution’s administration. A medical exemption requires a signed certiﬁcation by a physician licensed to

practice in Missouri indicating that the immunization would seriously endanger the student’s health or life of the student has

documentation of the disease or laboratory evidence of immunity to the disease.

Comments:

_________________________________________________

_______________________________________________________________

___________________________________

PRINTED NAME OF PHYSICIAN

SIGNATURE OF PHYSICIAN

SIGNATURE DATE

Physicians’ Address: _______________________________________________________________________________________

City/State/Zip Code: ________________________________________________________________________________________

Phone Number: ___________________________________________________________________________________________

Religious Exemption

After consulting my healthcare provider, Student Health Center, or local or state health department, I understand the risks of

not being vaccinated for meningococal disease. Initial: _________

A. To be completed by student 18 years of age or older:

I do not choose to get the meningococcal vaccine at this time, due to my religious beliefs.

Signature: __________________________________________________________________ Date: ________________________

B. For students under the age of 18:

As the parent of a legal guardian, I do not want this student to get the meningococcal vaccine at this time, due to our

religious beliefs.

Printed Name of Parent/Legal Guardian: ___________________________________________ Date: ________________________

Signature of Parent/Legal Guardian: ______________________________________________ Date: ________________________

Fax, bring or mail this form to:

Truman State University Student Health Center

100 E. Normal Ave.

Kirksville, MO 63501-4221

Phone: (660) 785-4182

Fax: (660) 785-4011

E-mail: pjohnson@truman.edu

Meningococcal Vaccination Waiver Form