MENINGITIS VACCINATION WAIVER FORM

MENINGITIS VACCINATION WAIVER FORM
Read this document carefully. Future registration for classes at Lincoln University will be blocked until this form is completed.
College students, especially freshman living in residence halls, are at a slightly increased risk for contracting meningococcal meningitis. The bacterial form of this disease can lead to serious complications such as; swelling of the brain, coma, and even death within a short period of time. A vaccine is currently available that will decrease, but not completely eliminate a person's risk of acquiring meningococcal meningitis. This element of uncertainty remains because the current vaccine does not protect against one strain of the disease. The vaccine, Menactra, probably protects for 3-5 years and is extremely safe to use.
Please check the following block(s) that apply to you:
Date

MonthDayYearHourMinutesAM/PM Option
Full Name

First NameLast Name
Student ID number or Social Security Number
Birth Date

MonthDayYear
Proof of Meningitis vaccination may be uploaded here

Upload a File

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If proof of immunization is being submitted, an official letterhead (from a doctor's office, clinic, or health department) and authorized healthcare professional's signature must appear on document.
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