In accordance with Missouri Senate Bill 686, which states:
"Section 1.1 Beginning with the 2004-2005 school year and for each school year thereafter, every public institution of higher education in this state shall require all students who reside in on-campus housing to sign a written waiver stating that the institution of higher education has provided the student, or if the student is a minor, the student's parents or guardian, with detailed written information on the risks associated with the meningococcal disease and the availability and effectiveness of the meningococcal vaccine.
2. Any student who elects to receive the meningococcal vaccine shall not be required to sign a waiver referenced in subsection 1 of this section and shall present a record of said vaccination to the institution of higher education."
Truman state University now requires all students living in Residential Colleges to either show proof of the meningococcal vaccine (within 3 years) OR sign the waiver below. STUDENTS WILL NOT BE ALLOWED TO MOVE IN TO THEIR RESIDENCE HALL UNTIL THIS REQUIREMENT IS MET.
STUDENT NAME_________________________________ SSN___________________________
BANNER NUMBER (STUDENT ID NUMBER)_____________________________________________
Vaccine Waiver: To be completed by the individual (or parent/guardian for individuals less that 18 years of age).
SECTION 3A: For individuals 18 years of age or older:
I am 18 years of age or older. I have received and read the information in the brochure provided by Truman State University, which explained the risks of meningococcal disease. I am aware of the effectiveness and availability of the vaccine at the Student Health Center. I am aware that meningococcal disease is a rare, but life-threatening illness. I understand that students residing in on-campus housing must be vaccinated against meningococcal disease or sign a waiver. I voluntarily agree to release, discharge indemnify and hold harmless Truman State University, its officers, employees and agents from any and all costs, liabilities expenses, claims or causes of action on account of any loss or personal injury that might result from my decision not to be immunized against meningococcal disease.
NAME OF STUDENT______________________________ SIGNATURE OF STUDENT____________________________
DATE___________________________________________
For individuals under 18 years of age, a parent or guardian must complete Section 3B
I am the parent/guardian of __________________________________________. I have received and read the information in the brochure provided by Truman State University about meningococcal disease and am aware of the effectiveness and availability of the vaccine at the Student Health Center. I am aware that meningococcal disease is a rare, but life-threatening illness. I understand that students residing in on-campus housing must be vaccinated against meningococcal disease or sign a waiver. I voluntarily agree to release, discharge, indemnify and hold harmless causes of action on account of any loss or personal injury that might result from my decision not to have the above-named individual immunized against meningococcal disease.
NAME OF PARENT/GUARDIAN__________________________________________________
SIGNATURE OF PARENT/GUARDIAN_____________________________________________ DATE_____________________________