For the (health) record
Please complete this form and return it to:
Fax:
(316) 295-5215
Mail:
Friends University
Residence Life
2100 W. University Ave.
Wichita, Kansas 67213
(316) 295-5500
*Please include a copy of your immunization records that indicate you
have received the meningitis vaccine OR submit the waiver.
Tell us about yourself:
Name: Please print._________________________________________________________
Home Address: ___________________________________________________________
Date of Birth: ____________________________________________________________
Student Phone #: _________________________________________________________
Email Address: ___________________________________________________________
Date of Entrance _________________________________________________________
Gender: Female Male
Marital Status: Single Married Widowed Divorced
Emergency Contact(s):
Person to Call in an Emergency ________________________________
Relationship _______________________________________________
Phone_____________________________________________________
Person to Call in an Emergency ________________________________
Relationship _______________________________________________
Phone_____________________________________________________
Health Information:
This section allows you to provide us with information regarding your health status, and may
assist in a time of medical emergency. This information will be kept in your confidential
housing file, and shared only in the event of a medical emergency.
CURRENT/CHRONIC HEALTH ISSUES:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
CURRENT MEDICATIONS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
ALLERGIES (medicine, food, other):
_____________________________________________________________________________
___________________________________________________________________
OTHER HEALTH INFORMATION YOU WOULD LIKE TO SHARE:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
Friends University Health and Wellness Office
Meningitis Vaccination and Disease Information Form
Revised July 2015
The mission of the Friends University Health & Wellness Office is to assist students in maintaining their optimal level of health
and wellness. We are here to help you have a healthy college life. Immunizations are an important aspect of maintaining good
health. If you haven’t already done so, we recommend updating all of your adult vaccinations.
The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) has established guidelines for
the meningitis vaccine aimed at all new students including college freshmen living in campus-owned student housing. The
American College Health Association (ACHA) supports these guidelines. In response to these efforts, the State of Kansas has
mandated that “all incoming students residing in university housing be vaccinated for meningitis or sign a waiver indicating that
they refuse to take the vaccine” effective July 1, 2007.
In an attempt to reduce the risk of this serious disease among the college population and in compliance with State policy,
Friends University requires that each first-time resident of a University owned housing show proof of a current
meningitis vaccine or complete and submit a Meningitis Vaccination and Disease Information Waiver. Immunizations
help decrease the risk of contracting serious diseases. We are aware reactions can occur with vaccinations. Most reactions are
minimal and the vaccine is much safer than getting the disease.
Meningitis is a potentially life threatening bacterial infection. It can cause hearing loss, kidney failure, amputation of limbs
and permanent brain injury. The disease can progress rapidly, causing serious problems in as little as 12 hours. Each year the
disease strikes about 3,000 people in the United States. Death occurs in approximately 10% of cases. With the vaccine, the
majority of cases in the college age population are preventable. It is highly recommended that the student be vaccinated prior to
coming to Friends University. The vaccine may be covered by your health insurance. Visit the Center for Disease Control site
at www.cdc.gov for further information on meningitis and meningitis vaccinations.
Please complete and return this form along with the appropriate documentation to the Residence Life Office. Proof of the
meningitis vaccine or a signed waiver must be presented to the Residence Life Office prior to moving into any Friends
University residential facility. For questions call the Residence Life office at 316.295-5500. Proof of vaccination and/or this
form may be faxed to 316.295.5215 or emailed to reslife@friends.edu.
---------------------------------------------------------------------------------------------------------------------------------------------------------
______ I have read the information above & understand the possible consequences of not receiving the meningitis vaccine.
I do not wish to receive the vaccine at this time. I also understand that by refusing the meningitis vaccine, in the event of a
meningitis outbreak on campus, the student named below will be referred to the Sedgwick County Health Department.
Print student’s name: ____________________________________________________________________________
Student’s Date of Birth: _________________________________________________________________________
_____________________________________________________________________Date: ___________________
Signature (parent, guardian, emancipated student, or student 18 years and older)
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