Cayuga Community College Health Services Office
Phone 315-255-1743 Fax 315-253-0063
New York State Public Law requires that all college students enrolled for at least 6 credit hours, or the equivalent, per semester, complete and return this form to their school health office. Please return your signed form to:
Cayuga Community College
Health Services Office
197 Franklin Street
Auburn, NY 13021
Please check one box, sign below, and fill in the blank lines.
I have (for students under the age of 18: My child has):
q had meningoccocal meningitis immunization within the past 10 years:
¡ MenomuneTM (meningococcal polysaccharide vaccine)
Date:__________________________________
Note: If you (your child) received MenomuneTM , the meningococcal vaccine available before February 2005, please note that this vaccine’s protection lasts for approximately 3 to 5 years. Revaccination with new conjugate vaccine called MenactraTM should be considered within 3 to 5 years after receiving MenomuneTM.
¡ MenactraTM (meningococcal conjugate vaccine)
Date:__________________________________
q read, or have had explained to me (my child), 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.
Signed ________________________________________ Date _____ ⁄ _____ ⁄ _____
(Parent/guardian if student is a minor)
Please print:
Student’s name ____________________________________________
Student’s date of birth _____ ⁄ _____ ⁄ _____
Student’s e-mail address _____________________________________
Student’s Social Security number _____________________________________
Student’s mailing address _________________________________________________________________
_________________________________________________________________
Student’s phone number ( )______________________________