Meningococcal
Meningitis and Hepatitis B
Florida
Statutes requires students who live in an on-campus residence hall to provide
documentation of vaccinations against meningococcal meningitis and
hepatitis B OR sign a waiver declining the
vaccinations. Please complete and return
to:
Admissions
and Records Office
Student Name _________________________________________________________________
(PRINT) First Middle Last
SS# _________________________________ Date of Birth ________________________
Month/Date/Year
I have received the required information
regarding the risks of acquiring bacterial meningitis and Hepatitis B and the
benefits of receiving immunizations to reduce those risks. I also understand that I am required to
receive these immunizations or actively decline these immunizations. This
form has been truthfully completed to the best of my knowledge and I freely
consent to this form being used for my registration at
__________________________________ __________________________________
Student’s Signature Date
Hepatitis B: Dose 1:
___________________ Meningococcal Meningitis ___/___/___
Dose 2: ___________________
Dose 3: ___________________
____________________________ ___________ ___________________________________
Physician/Authorized Signature Date License # and Office Stamp
with Address
____ I decline receiving Menomune vaccine for bacterial meningitis. I acknowledge receipt of
information regarding this disease.
____ I decline receiving Hepatitis B
vaccines. I acknowledge receipt of
information regarding this
disease.
_____________________________________ __________________________________
Student’s Signature Date
REQUIRED AUTHORIZATION FOR
STUDENTS UNDER AGE OF 18. I concur with the above:
________________________________________ _____________________________________