I understand that the Centers for Disease Control (CDC), the Advisory Committee on Immunization Practices (ACIP) and the American College Health Association (ACHA) recommend that all incoming freshmen residing in Residence Halls receive the meningococcal vaccine, Menactra. I have read the risks and benefits of the vaccine and acknowledge the detrimental health effects of the disease. I have read and understand the availability and effectiveness of the vaccine which is available at my local health department.
I do not wish to receive the vaccine and I voluntarily agree to release, discharge, indemnify and hold harmless Sierra Community College, its officers, employees and agents from any and all costs and liabilities, expenses, claims, demands or causes of action on account of any loss or personal injury that might result from my non-compliance with current recommendations.
To be filled out by the student and parent/guardian, if applicable. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver.
Student Signature: _______________________________ Date: _____________
If the student is under age 18, a parent/guardian also must sign this waiver.
Signature of Parent/Guardian: _______________________ Date: _____________
Name of Parent/Guardian (printed): _______________________________________