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:*

I have read the information provided about meningococcal disease/vaccine. I decline receipt of vaccine for meningococcal meningitis. I have received the vaccine and will provide proof as noted below.

Date

/ Month / Day Year

at

: Hour Minutes

Full Name*

First Name Last Name

Student ID number or Social Security Number*

Birth Date*

Month Day Year

Proof of Meningitis vaccination may be uploaded here

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.

MENINGITIS VACCINATION WAIVER FORM