Dickinson College

STUDENT MEDICAL WAIVER AND RELEASE FORM

MENINGOCOCCAL DISEASE

A meningitis wavier statement is located on the bottom of page one of the Medical Record form. Please use this form only if the waiver section on page one was not signed prior to returning it to the Health Center .

I, _________________________________, certify that I have been provided with written information by Dickinson College explaining the risks associated with meningococcal disease, and the availability and effectiveness of vaccination against the disease and I have reviewed this information. Notwithstanding the information provided, for religious or other reasons, I choose not to be vaccinated against meningococcal disease.

I acknowledge that I am making my decision not to be vaccinated with the full realization that there may be a significant risk of bodily injury, including death, if I contract the disease.

I hereby assume all the risks associated with my decision not to be vaccinated, and agree to release and hold harmless Dickinson College, its trustees, officers, agents, and employees, from any and all liability, actions, causes of action, negligence, debts, claims, or demands of any kind and nature whatsoever including, but not limited to, claims for negligence, recklessness or any other form of action for which a release may be legally given (including attorneys’ fees and costs) which may arise by or in connection with my decision.

I agree further to hold harmless and indemnify the College, its trustees, officers, agents and employees from any and all liability, actions, causes of action, negligence, debts, claims or demands of any kind and nature whatsoever (including attorneys’ fees and costs) by any person, including the College which may arise by or in connection with my decision not to be vaccinated.

I hereby certify that I voluntarily sign this waiver and release, and intend to be legally bound by the terms of this document. I have read all of its provisions, and fully understand its significance.

I further understand that by State law I will not be allowed to reside in a residence hall on campus unless I have either received the vaccine within the past 3 years or declined the vaccine by completing verification / waiver form.

q I decline the vaccine.

q I decline the vaccine at this point in time, but may wish to have it at a later date.

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Please print name Date of Birth

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Student’s signature - age 18 or older        Date
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Parent's/Guardian's signature - if student under age 18