Meningococcal Decline Form

A separate, signed application must be submitted for each individual to receive an exemption from Florida meningococcal vaccination requirements.

Please complete the required fields: first name, last name, date of birth (in MM/DD/YYYY format) and zip code.

Read the Risks and Benefits of Meningococcal Vaccination below. After reading the Risks and Benefits, complete the Authorization section of the form and submit it to us.


Vaccine Preventable Disease
Meningococcal disease is an acute, potentially severe illness that most often causesmmeningitis, an infection of the spinal fluid and the fluid that surrounds the brain. It leads to sudden onset of fever, headache, and stiff neck and is usually accompanied by nausea, vomiting, light sensitivity and altered mental status. Less commonly it can cause pneumonia, arthritis and ear/throat infections. Meningococcal disease can result in hearing loss, nervous system problems, seizures, strokes, loss of limbs (arms, legs) or even death.
Effectiveness Of Vaccine
A protective level of antibody is usually achieved within 7-10 days of vaccination. The vaccines protects about 90% of individuals who get them.

Possible Side Effects Of Vaccine
The most common side effects are redness or pain at the injection site lasting 1-2 days, headache, and fatigue. Serious allergic reactions are very rare.


Meningococcal Decline Form

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.