Immunization History Form - Manhattan School of Music

Meningitis Immunity Form
TO BE COMPLETED BY STUDENT OR GUARDIAN. Doctor’s signature is not required.
Return by:
• FAX to 212-749-3025
• SCAN & EMAIL to admission@msmnyc.edu
• MAIL to Office of Admissions, 120 Claremont Ave, New York, NY 10027
Due Dates:
• For SES Students – Due May 1, 2013
• For All Others – Due August 1, 2013
New York State Public Health Law requires that all college and university students, enrolled for at least six (6) semester
hours or the equivalent per semester, complete this form. If the student is under the age of 18, a legal parent or
guardian must complete this form.
SELECT A BOX:
I have (or my child has) had the meningococcal meningitis immunization (Menomune, MPSV4,
Menactra) within the past 10 years.
DATE MENINGITIS IMMUNIZATION RECEIVED
Month: ____________ Day: _____________ Year: ____________________
(Note: Must be received within the last 10 years to be considered valid)
I have (or my child has) 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 I (my child) will
not obtain immunization against meningococcal meningitis disease.
STUDENT SIGNATURE & INFORMATION
(Parent/Guardian should sign for those students who are under 18 years old)
__________________________________________________________ _____________________________________
STUDENT SIGNATURE (or Parent/Guardian for minors) Date
___________________________________________________ ___________________________________ __________________________
Name (print) Instrument (also indicate whether classical, jazz, or contemporary) Degree Level
_______________________________ ___________________ ______________________________ ______________________________
Date of Birth AppID# Telephone Number Cell Phone Number
___________________________________________________________________________________________________________________
E-mail Address
___________________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________________
City State Zip