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Meningitis Vaccination Response Form
New York State Public Health Law requires the operator of an overnight children's camp to maintain a completed response form for every camper who attends camp for seven or more nights
Choose one option and sign below:
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My child had the meningoccal meningitis immunization within the past 10 years
I have read or have had explained to me the information regarding the meningitis desease. I understand the risks of not receiving the vaccine. I have decided that my child will not obtain immunization against meningoccal miningitis desease
Date Received
Camper's Name
*
First
Last
Date of Birth
*
Phone
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Iowa
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Maine
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent Initials
*
Date
*
Date Format: MM slash DD slash YYYY