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STUDENT HEALTH SERVICE Tel 631 632-6740 TDD 631 632-6171 Fax 631 632-6936 When Completed Mail Directly to Director Student Health Service Stony Brook University Stony Brook New York 11794-3191 Meningitis Response Form STUDENT LAST NAME PLEASE PRINT FIRST NAME MIDDLE NAME STONY BROOK ID HOME ADDRESS STREET/APT. CITY/TOWN STATE/PROVINCE HOME PHONE CELL PHONE E-MAIL EMERGENCY CONTACT RELATIONSHIP PHONE ZIP CODE COUNTRY IF NOT U*S* New York State Public Health Law and Stony Brook University Policy require that all students must verify by their signature that they have received information about meningococcal disease and have made an informed decision about whether or not to receive immunization against meningococcal disease. Student must demonstrate compliance with this requirement within 30 days after the first day of classes. The Registrar will block and de-register students who fail to comply with this health requirement. Student may comply with this law by reading the required information regarding meningitis at this Web site http //studentaffairs. stonybrook. edu/shs/docs/Meningitis. pdf and then completing this form* If you are 18 years of age or older or you do not wish to use this form this requirement can be met by logging on to your SOLAR account and reading the information and submitting your response electronically. Your response to this form must be received two weeks before your Orientation date. It is important that we receive the immunization information before that date so your form can be processed early to avoid registration/de-registration problems. Check one box and sign below. I have For students under the age of 18 My child has had the meningococcal meningitis immunization Menomune or within the past 10 years. Date received read or have had explained to me the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I my child will not obtain immunization against meningococcal meningitis disease. SIGNATURE PARENT/GUARDIAN IF STUDENT IS A MINOR DATE PLEASE REMEMBER TO MAKE A COPY OF THIS FORM FOR YOUR RECORDS BEFORE YOU SEND IT IN*. CITY/TOWN STATE/PROVINCE HOME PHONE CELL PHONE E-MAIL EMERGENCY CONTACT RELATIONSHIP PHONE ZIP CODE COUNTRY IF NOT U*S* New York State Public Health Law and Stony Brook University Policy require that all students must verify by their signature that they have received information about meningococcal disease and have made an informed decision about whether or not to receive immunization against meningococcal disease. Student must demonstrate compliance with this requirement within 30 days after the first day of classes. Student must demonstrate compliance with this requirement within 30 days after the first day of classes. The Registrar will block and de-register students who fail to comply with this health requirement. Student may comply with this law by reading the required information regarding meningitis at this Web site http //studentaffairs.

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