Meningococcal Meningitis and Hepatitis B

Vaccine Verification/Waiver

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

Chipola College

3094 Indian Circle

Marianna, Florida 32446-1053

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 Chipola College or any other college/university.

__________________________________                __________________________________

Student’s Signature                                                      Date

SECTION A: Immunization Verification - To be completed by medical personnel.

Hepatitis B: Dose 1: ___________________                 Meningococcal Meningitis ___/___/___

                     Dose 2: ___________________

                     Dose 3: ___________________

____________________________   ___________   ___________________________________

Physician/Authorized Signature        Date                 License # and Office Stamp with Address

SECTION B: Vaccine Waiver - To be completed by Student/Parent/Guardian

A separate waiver for each of these vaccines must be signed.

____ 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:

________________________________________                _____________________________________

Signature of Parent/Guardian             Date