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Get Seton Hill University Meningitis Immunization Form

MENINGITIS IMMUNIZATION FORM Complete the top half of the form and the section indicating conformation or exemption as appropriate. Obtain signatures as required and attach to the Health History Form. The American College Health Association and Seton Hill University supports the meningococcal vaccination recommendation issued by the Advisory Committee on Immunization Practices ACIP of the Center for Disease Control and Prevention CDC. Obtain signatures as required and attach to the Health History Form. The American College Health Association and Seton Hill University supports the meningococcal vaccination recommendation issued by the Advisory Committee on Immunization Practices ACIP of the Center for Disease Control and Prevention CDC. This recommendation states that College freshmen dormitory residents are informed about meningitis and the benefits of vaccination. Seton Hill University strongly urges students to receive the meningitis vaccine. MENINGITIS IMMUNIZATION FORM Complete the top half of the form and the section indicating conformation or exemption as appropriate. Obtain signatures as required and attach to the Health History Form* The American College Health Association and Seton Hill University supports the meningococcal vaccination recommendation issued by the Advisory Committee on Immunization Practices ACIP of the Center for Disease Control and Prevention CDC. This recommendation states that College freshmen dormitory residents are informed about meningitis and the benefits of vaccination* Seton Hill University strongly urges students to receive the meningitis vaccine. This immunization can only be refused for religious or strong moral reasons according to PA Senate Bill 955 session of 2001. Name Please Print Date of Birth Address Telephone Parent or Guardian if under 18 CONFIRMATION OF IMMUNIZATION The above named received the meningitis vaccine in my office. Date given Physician Name Physician Signature Or attach a copy of the receipt from your doctor confirming vaccine EXEMPTION FROM VACCINATION I have been given a copy and have read and understand the information in the Meningococcal Vaccine Information Statement for Meningococcal disease. I believe that I understand the benefits and risks however I am requesting exemption from the College and University Student Vaccination Act. This recommendation states that College freshmen dormitory residents are informed about meningitis and the benefits of vaccination* Seton Hill University strongly urges students to receive the meningitis vaccine. This immunization can only be refused for religious or strong moral reasons according to PA Senate Bill 955 session of 2001. This immunization can only be refused for religious or strong moral reasons according to PA Senate Bill 955 session of 2001. Name Please Print Date of Birth Address Telephone Parent or Guardian if under 18 CONFIRMATION OF IMMUNIZATION The above named received the meningitis vaccine in my office. Name Please Print Date of Birth Address Telephone Parent or Guardian if under 18 CONFIRMATION OF IMMUNIZATION The above named received the meningitis vaccine in my office. Date given Physician Name Physician Signature Or attach a copy of the receipt from your doctor confirming vaccine EXEMPTION FROM VACCINATION I have been given a copy and have read and understand the information in the Meningococcal Vaccine Information Statement for Meningococcal disease.

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