Meningitis – The Wayfinder Experience

Meningococcal Meningitis Vaccination Response Form

New York State Public Health Law requires that a parent or guardian of campers who attend an overnight children’s camp for seven or more consecutive nights, complete and return the following form to the camp.

Check one box and sign below.
- My child has had meningococcal meningitis immunization within the past 10 years. Date received:
[Note: If your child received the meningococcal vaccine available before February 2005 called Menomune™, please note this vaccine’s protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine called Menactra™ should be considered within 3-5 years after receiving Menomune™.]
- I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that my child will not obtain immunization against meningococcal meningitis disease.
Parent/Guardian Name
First Last
Date
Date Format: MM slash DD slash YYYY
Signature
Camper's Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent/Guardian Email (optional)