Meningitis Form (Page 3 of 3) in pdf

Meningitis Form

(Please retain a copy for your files.)

Student Health Services

Queens and Manhattan Campuses

Staten Island Campus

8000 Utopia Parkway

Campus Center

300 Howard Avenue

Queens, NY 11439

Tel 718-990-6360

Staten Island, NY 10301

Fax 718-990-2368

Tel 718-390-4447

stjohns.edu

Fax 718-390-4480

Name: ________________________________________

Date of Birth: ______________________

Address: __________________________________________________________________________

Student X #: _______________________________________________________________________

__________________________________________________________________________________

St. John’s University is in compliance with New York State Public Health Law 2167, requiring all

college and university students and parents or guardians (if student is under age 18) to complete

and return this form to Student Health Services at the address above.

All students (and parents or guardians if student is under age 18) must complete and

sign below. Please note: It is necessary to complete this form even if documentation of this

vaccine is already on file.

CHECK ONE BOX AND SIGN BELOW:

Had the meningococcal meningitis vaccine at age 16 years or older. Date: _______________

Health care provider’s signature: _________________________________________________

Address: ____________________________________________________________________

License # : _______________________________

Tel: ______________________________

Stamp: ______________________________________________________________________

I have (for students under age 18: “My child has”):

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.

Signed: _______________________________________

Date: ____________________________

(Parent/guardian if student is under age 18)

Meningitis Form Page 3