Ursinus College
____________________________________________ _________________
____________________________________________ _________________
MEDICAL WAIVER AND RELEASE FORM
MENINGOCOCCAL DISEASE
I, _____________________________________, certify that I have been provided with written
information by Ursinus College explaining the risks associated with meningococcal disease, and the
availability and effectiveness of vaccination against the disease and I have reviewed this
information. Notwithstanding the information provided, for religious or other reasons, I choose not to
be vaccinated against meningococcal disease.
I acknowledge that I am making the decision not to be vaccinated with the full realization that there
may be a significant risk of bodily injury, including death, if I contract the disease.
I hereby assume all the risks associated with my decision not to be vaccinated, and agree to release
and hold harmless Ursinus College, its trustees, officers, agents and employees, from any and all
liability, actions, causes of action, negligence, debts, claims or demands of any kind and nature
whatsoever including, but not limited to, claims for negligence, recklessness or any other form of
action for which a release may be legally given (including attorneys’ fees and costs) which may arise
by or in connection with my decision.
I agree further to hold harmless and indemnify the College, its trustees, officers, agents and
employees, from any and all liability, actions, causes of actions, negligence, debts, claims or
demands of any kind and nature whatsoever (including attorneys’ fees and costs) by any person,
including myself or the College, which may arise by or in connection with my decision not to be
vaccinated.
I hereby certify that I voluntarily sign this waiver and release, and intend to be legally bound by the
terms of this document. I have read all of its provisions and fully understand its significance.
I understand by State law that I will not be able to reside in a residence hall on campus unless I have
either received the meningitis vaccine within the last 5 years (and that information has been
documented on my immunization record) OR this waiver form has been signed.
_______ I decline the vaccine. (Please check this area if declining)
____________________________________ ______/______/________
Student’s name (please print) Student’s date of birth
Signature Date
Parent’s signature (if student is under 18 years of age) Date
Ursinus College Wellness Center
601 E. Main St. Collegeville, PA 19426
PH: 610-409-3100 FAX: 610-409-3778
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MENINGITIS VACCINE
The Pennsylvania legislature requires colleges and universities to inform all resident students about
meningitis. The law dictates that all resident students are required to either receive a meningitis
vaccine or sign a waiver stating that they have read the information and have decided to not receive
the vaccination. Under the provisions of this law, colleges and universities “shall prohibit a student
from residing in a dormitory or housing unit” without proof of immunization or a signed waiver. The
full transcript of this law is available at http://www.ncsl.org/research/health/meningitis-state-
legislation-and-laws.aspx#introleg2011
The medical waiver and release form is included on the reverse side of this paper.
In order to make an educated decision on whether or not to be vaccinated, please read the following
information on meningitis:
Meningitis is an inflammation and infection of the lining of the brain and spinal cord caused by either
a virus or bacteria. Viral meningitis is more common than bacterial meningitis and usually occurs in
late spring and summer. Signs and symptoms of viral meningitis may include stiff neck, headache,
nausea, vomiting and rash. Most cases of viral meningitis run a short, uneventful course and do not
require antibiotics. Persons who have had contact with an individual with viral meningitis do not
require treatment.
Bacterial meningitis occurs rarely and sporadically throughout the year. Bacterial meningitis
(meningococcal meningitis) can cause grave illness and rapidly progress to death and therefore
requires early diagnosis and treatment. Persons who have had intimate contact with someone who
has been diagnosed with meningococcal meningitis should seek immediate medical attention. These
organisms can be transmitted through close personal contact such as sharing drinking or eating
utensils, sharing the mouthpiece on a musical instrument, sneezing or coughing on someone, kissing
on the lips or sharing cigarettes.
After receiving the vaccine, localized redness in the injection site can be expected for 1-2 days.
Additionally, a person may experience headache, fatigue, fever and chills. The vaccine should not be
given to a person who has a fever, or anyone allergic to Thimerosal (a preservative used in the
vaccine) or to latex. Women who are pregnant should not receive the vaccine and those who are
receiving immunosuppressive therapy will not receive the full benefits of the vaccine. As with all
vaccines, there is a chance of an allergic reaction or anaphylactic shock which may lead to death.
If you would like more information on meningitis and the vaccine, please visit the center for Disease
Control (CDC) website at httphttp://www.cdc.gov/meningococcal/
Ursinus College Wellness Center
601 E. Main St. Collegeville, PA 19426
PH: 610-409-3100 FAX: 610-409-3778
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