Vaccination Response Form

Five Towns College > Vaccination Response Form

Meningococcal Meningitis Vaccination Response Form

New York State Public Health Law 2167 requires that all college and university students enrolled for at least six (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return the following form to Five Towns College.
Check one box and sign below.
- I have (for students under the age of 18: My child has):
  - had the meningococcal meningitis immunization (Menomune TM or Menactra) within the past 10 years.
- Date Received:*
  Date Format: MM slash DD slash YYYY
- read, or have had explained to me, the information regarding meningococcal meningitis disease. I (my child) will obtain immunization against meningococcal meningitis within 30 days from my private health care provider.
- 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.
- Student E-mail Address*
  Enter Email Confirm Email
- Student Date of Birth*
  Date Format: MM slash DD slash YYYY
Student Mailing Address
Street Address Address Line 2 City State ZIP Code
- Student's Name*
  First Last
- Student ID#*
- Student Phone Number
- Signature*

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Five Towns College

305 North Service Road,
Dix Hills, NY 11746
Phone: 631.656.2110
Fax: 631.656.2172

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Vaccination Response Form

Meningococcal Meningitis Vaccination Response Form

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