Meningococcal Vaccine Tracking

Required for all those who complete a housing contract.

MENINGOCOCCAL VACCINE TRACKING

In accordance with Missouri State Law

FILL OUT SECTION 1 OR 2

STUDENT NAME:_________________________________ID#_______________________


#1

IMMUNIZATION STATUS I have received the meningococcal vaccine. Please provide the date of receiving the meningococcal vaccine by attaching a copy of your health record if possible.

Date of meningococcal vaccine: _______________________

Student signature:______________________________________

Date:_______________________


#2

VACCINE WAIVER

For individuals 18 years of age and older: I am 18 years of age or older. I have received and read the information in the Meningococcal Disease Fact Sheet, written by the Center for Disease Control and Prevention, and provided by Drury University explaining the risks of meningococcal disease and the potential benefits of vaccination. I also understand the vaccine is available through my private health care provider or Health department. I have not yet received the vaccine, although, at my discretion, I may choose to do so at some time in the future.

Signature of student:___________________________________

Date:_______________________

For individuals under the age of 18: I am the parent or guardian of

_________________________________ who will be a student at (name of individual enrolled) Drury University. I have received and read the information in the Meningococcal Disease Fact Sheet, written by the Center for Disease Control and Prevention, and provided by Drury University, explaining the risks of meningococcal disease, and the potential benefits of vaccination. I also understand the vaccine is available through my private health care provider or Health departments. My student has not yet received the vaccination, although at our discretion, he/she may choose to do so at some time in the future.

Name of parent/guardian:________________________________

Date: ______________________

Signature of parent/guardian: ____________________________