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)
