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:*
- 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 State ZIP Code
Parent Initials*
Date*
MM slash DD slash YYYY