Bacterial Meningitis Compliance Form Please print: Student Name: First Middle Last SJC ID#: G#:

Date of Birth: Month Day Year Telephone:

Email Address: Date Submitted:

Please read and place an “X” next to the section that applies to you. Sign, date, and submit to the Office of Enrollment Services by mail, fax, or in person.

I have received the Bacterial Meningitis Vaccine or booster within the last 5 years and am attaching an official vaccination record.

I understand that evidence of the vaccination must be one of the following: 1. The signature or stamp of a physician or his/her designee, or public health authority: or2. An official immunization record generated from a state or local health authority; or3. An official record received from school officials, including a record from another state.

The vaccination or booster must not be more than 5 years old as of the first day of the term in which I plan to enroll.

I am under the age of 18 and am declaring a temporary waiver for reasons of conscience, including a religious belief and am attaching a signed, notarized conscientious exemption form from the Texas Department of State Health Services. I understand that this temporary waiver is only valid for 2 years and at that time I must apply for an additional temporary waiver or comply with the Meningitis requirement.

I am 18 years of age or older and am declaring an exemption for reasons of conscience, including a religious belief and am attaching a signed conscientious exemption affidavit from the Texas State Health Services Department which can be found at https://corequestjc.dshs.texas.gov/.

I am declaring a temporary waiver for the ________________ (fall/spring/summer) semester because I am enrolling ONLY in distance learning courses that are taught 100 percent online. (Session Description of (Online-100 percent Computer/Web). I understand that I must request this temporary waiver each semester and when I am no longer enrolled in only 100 percent Online Distance Learning classes, I must comply with the Meningitis requirement.

I am declaring a temporary waiver due to a medical exemption affidavit or certificate signed by a physician who is duly registered and licensed to practice medicine in the U.S., in which it is stated that, in the physician’s opinion, the vaccination required would be injurious to the health and well-being of the student. I understand that when the affidavit is no longer valid, I must comply with the Meningitis requirement.

I certify that the information I have submitted is accurate and that I will abide by the regulations.

Student/Parent or Guardian Signature:

For Office Use Only: Date Received: Received By:

Central Campus: 8060 Spencer Highway, Pasadena, Texas 77505 North Campus: 5800 Uvalde Road, Houston, Texas 77049 South Campus: 13735 Beamer Road, Houston, Texas 77089 Fax: 281-669-4720Email: Meningitis.Docs@sjcd.edu

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