MVCC HEALTH INFORMATION FORM
ALL STUDENTS MUST COMPLETE THIS FORM BEFORE SCHEDULING FOR CLASSES
.
New York State requires all students born on or after January 1, 1957, registered for 6 or more credit hours, to
provide proof of immunity or immunization to measles, mumps, and rubella and sign the Meningitis Response
Form. Ways of obtaining immunization records are found at mvcc.edu/FAQ.
Name: ______________________________________________________ Student M# __________________
Last First Preferred Name
Gender Identity: _______________ Birth Date: ___/___/___ Entering: Fall:___Spring:___Summer:__Year: 2020
OPTION #1: Complete the MENINGITIS RESPONSE, sign the BOTTOM AND COMPLETE THE BACK.
SUBMIT FORM WITH A COPY OF YOUR IMMUNIZATION RECORD. If under18 years of age, a
parent/guardian signature is needed. Thank you.
OPTION #2: Have your healthcare provider complete and sign table below. Answer the
MENINGITIS RESPONSE, sign the BOTTOM, AND COMPLETE THE BACK. If under 18 years of age, a
parent/guardian signature is needed. Thank you.
MENINGITIS RESPONSE - ALL STUDENTS MUST COMPLETE
Check one box: I have (for students under the age of 18: My child has):
had a meningococcal immunization within the past 5 years. The vaccine record is attached.
I plan to obtain immunization against meningococcal disease within 30 days from my private health care
provider or other public or private health care provider.
I have either read, received, or acknowledge the website link below containing, the information regarding meningococcal
meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child, if under 18) will NOT
obtain immunization against the meningococcal disease at this time. http://www.mvcc.edu/health-center/meningitis .
X_____________________________ Age: ____ Date: _________ X_____________________________
Student’s signature Parent/guardian signature (under 18 years old)
Student’s Name:______________________________________ M#_________________
Authorization to Provide Medical Care Required for students under 18 years of age
(optional for students over 18 years of age)
I hereby authorize the Student Health Center at Mohawk Valley Community College to give medical care to
(Student Name) _________________________________at their request or to arrange such care as necessary in
the event of emergencies.
X_________________________________________________ ____/____/____
Signature of Student Date
X _________________________________________________ ____/____/____
Parent/Guardian Signature - (If student under 18 years of age) Date
Person to Notify in Case of a Medical Emergency (only called in an emergency)
Name: ________________________________________ Relation: _____________________________
Address: _______________________________________________________________________________
City ________________________________ State___________ Zip Code___________ Country _________
Phone (_______) ___________________ (_______) __________________ (_______) ________________
Day Night Cell
Please submit to:
By Mail: MVCC Health Center, 1101 Sherman Drive, Utica, NY 13501-5394
By Email:Hcenter@mvcc.edu
By Fax: 315-731-5854 (Utica) 315-334-7726 (Rome)
Office Telephone: 315-792-5452
Exemptions
Medical and Religious exemptions are allowed only as stated by NYS Public Health Law 2165.
Age exemptions require proof of date of birth; i.e., a copy of driver’s license.
.
Military Service exemptions are allowed to those veterans who have been honorably discharged from
the Military within the past 10 years. You will need to produce a copy of your honorable discharge; and
a request to the Military requesting your immunization records. A form letter is available in for you to
customize to mail to the Military to request your immunizations. Please see the Health Center in Utica or
Student Services in Rome for assistance.
Revised 10/2016
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