Quick Links

Student Information

Student's Full Name(Required)
Date of Birth(Required)


Please be sure to read the Risks and Benefits section above before entering your choices below.
I have read and I understand the Risks and Benefits of Meningococcal Vaccination information. I understand the risks of not vaccinating myself/child.(Required)
I do NOT want the individual named above to receive the meningococcal vaccine for reason of conscience, which may include a religious belief.
I certify that I am the student named above or the parent or legal guardian of the student named above and that the information provided herein is true and correct.
Name of Authorizing Party(Required)
If the student is under 18, the parent or guardian must provide authorization.
This field is for validation purposes and should be left unchanged.