%PDF-1.3 %âãÏÓ 1 0 obj << /Producer (OmniForm Converter for PDF) /Creator (OmniForm Premium) >> endobj 4 0 obj [ /PDF /Text ] endobj 6 0 obj << /Length 7 0 R >> stream BT /F0 14 Tf 0 g 244.860 759.69 Td 92 Tz (ÎçÒ¹Ó°Ôº) Tj /F1 16 Tf -111.362 -19.928 Td 87 Tz (Meningococcal Vaccination Policy Compliance Form) Tj /F1 12 Tf -104.797 -73.318 Td 93 Tz (Student Information:) Tj ET .50 w 0 G 2 J 26.96 630.218 345.12 28.573 re S .75 w 2 J 372.078 630.218 109.68 28.573 re S .50 w 2 J 481.759 630.218 105.12 28.573 re S BT /F0 8 Tf 376.401 649.412 Td 108 Tz (Student number) Tj 109.44 0 Td 111 Tz (Date of Birth) Tj -283.442 -0.24 Td 114 Tz (First) Tj 140.882 -0.24 Td 117 Tz (M.) Tj -314.16 -0.238 Td 102 Tz (Name: Last) Tj /F1 14 Tf 140.987 -39.379 Td 92 Tz (For students who have received the vaccine) Tj /F1 12 Tf -140.882 -0.714 Td 86 Tz (Section 1) Tj -0.479 -17.983 Td 103 Tz /F2 10 Tf (I have received a meningococcal vaccine after my 16th birthday. A copy of the required documentation is attached.) Tj -0.479 -18 Td 100 Tz (Printed name of student:) Tj ET 2 J 323.637 554.683 m 135.17 554.683 l S BT 361.287 555.871 Td 112 Tz (Date:) Tj -333.45 -0.72 Td 101 Tz (Signature of student:) Tj /F1 14 Tf 163.925 -22.096 Td 87 Tz (Waivers \(complete part A or B\)) Tj /F1 12 Tf -162 -1.338 Td 90 Tz (Section 2) Tj 28.74 -18.53 Td 85 Tz (To be completed by students 18 years of age or older) Tj -28.74 0.383 Td 107 Tz (A.) Tj /F2 10 Tf 0 -144.984 Td 102 Tz (Printed name of student:) Tj ET 2 J 525.572 348.832 m 399.6 348.832 l S BT 365.28 349.061 Td (Date:) Tj -335.52 0.094 Td 110 Tz (Signature of student:) Tj /F1 12 Tf 36 -38.23 Td 91 Tz (For students under the age of 18) Tj -36.72 -0.479 Td 88 Tz (B.) Tj /F2 10 Tf 0.24 -143.92 Td 100 Tz (Printed name of parent/guardian:) Tj ET 2 J 345.572 146.906 m 169.832 146.906 l S 2 J 525.12 146.186 m 399.6 146.186 l S BT 364.683 148.334 Td 106 Tz (Date:) Tj -333.989 -0.96 Td 100 Tz (Signature of parent/guardian:) Tj /F1 12 Tf 114.267 -39.095 Td 85 Tz (Return completed form to one of the following campus addresses.) Tj /F3 9 Tf 162 -12.790 Td 105 Tz (Rolla Campus) Tj 0.96 -8.88 Td 106 Tz /F2 9 Tf (Student Health Services) Tj 0.96 -8.88 Td 117 Tz (910 West 10th Street) Tj -0.32 -8.88 Td 110 Tz (Rolla, MO 65409) Tj /F3 9 Tf 147.447 27.615 Td 101 Tz (St Louis Campus) Tj 0 -8.64 Td 104 Tz /F2 9 Tf (University Health Services) Tj 0 -8.64 Td 121 Tz (One University Blvd.) Tj 0.921 -8.64 Td 101 Tz (131 Millennium Student Center) Tj -0.201 -8.64 Td 100 Tz (St. Louis MO 63121-4499) Tj -0.72 -8.64 Td 96 Tz (Fax: \(314\) 516-5988) Tj /F3 9 Tf -276.616 44.084 Td 104 Tz (Kansas City Campus) Tj 0 -9.119 Td 100 Tz /F2 9 Tf (UMKC Residential Life Office) Tj 0 -9.119 Td 125 Tz (5051 Oak Street) Tj 0 -9.119 Td 100 Tz (Kansas City, MO 64110) Tj 0 -0.726 Td /F3 9 Tf -155.381 26.478 Td 99 Tz (Columbia Campus) Tj 0.96 -8.88 Td 101 Tz /F2 9 Tf (Student Health Center) Tj 0 -8.88 Td 115 Tz (1020 Hitt Street) Tj -0.023 -9.397 Td 104 Tz (Columbia, MO 65201) Tj 0.479 0.952 Td 430.82 -26.836 Td 97 Tz (Phone: \(314\) 516-5671) Tj -149.289 13.47 Td ( Phone: \(573\) 341-4284) Tj -280.885 -5.7 Td (Phone: \(573\) 882-4661) Tj 154.885 6.265 Td 96 Tz (Phone: \(816\) 235-8840) Tj ET .68 w 0 0 1 RG 0 J 25.696 30.929 m 159.313 30.929 l S 0 J 25.696 28.998 m 25.696 28.998 l S 0 J -6087355.313 790.852 m -6087355.313 790.852 l S 0 G 0 J -6087355.313 790.852 m -6086230.165 790.852 l S 0 w 0 J -6086230.165 792 m -6086230.165 792 l S 0 J -6086230.165 792 m -6086230.165 792 l S BT 0 0 1 rg 25.696 32.077 Td 113 Tz (www.studenthealth.missouri.edu) Tj 0 -1.93 Td 6087329.616 761.854 Td 16096 Tz 2001351.19 Tc 23408.856 Tw 0 g () Tj ET .68 w 0 0 1 RG 0 J 456.012 31.952 m 590.51 31.952 l S BT 0 0 1 rg 456.012 33.1 Td 100 Tz 0 Tc 0 Tw (http://www.umsl.edu/services/health/) Tj ET 0 J 309.206 31.388 m 439.214 31.388 l S 0 G 0 J 439.214 31.388 m 441.714 31.388 l S BT 306.96 32.536 Td ( ) Tj (http://campus.mst.edu/studenthealth) Tj 0 g (/) Tj ET 0 0 1 RG 0 J 177.36 28.363 m 276.900 28.363 l S BT 0 0 1 rg 177.36 29.511 Td 110 Tz (www.umkc.edu/housing/) Tj /F0 8 Tf 0 g -154.8 -9.082 Td 90 Tz (UM 55 \(SEP14\) 9/14/14) Tj ET .50 w 0 G 2 J 522.125 554.502 m 396 554.502 l S 2 J 345.6 348.832 m 169.2 348.832 l S BT /F2 9 Tf 26.164 59.630 Td 101 Tz (Fax: \(573\) 884-8902) Tj -0.003 -18.020 Td 90 Tz (Email: immunizations@health.missouri.edu) Tj /F2 10 Tf 1.837 676.134 Td 100 Tz (P) Tj /F2 11 Tf (lease return this form and the necessary documentation to the appropriate campus address as listed below. For additional) Tj 0 -11.001 Td (information on the meningococcal vaccine, see the following Centers for Disease Control \(CDC\) website:) Tj 0 -11.001 Td (http://www.cdc.gov/vaccines/hcp/vis/fis-statements/mening.html. If you do not have web access you may contact your) Tj 0 -11.001 Td (campus for information.) Tj ET .75 w 0 J 349.46 485.09 m 414.459 485.09 l S BT /F2 10 Tf 29.798 497.367 Td (I am 18 years of age or older. The ÎçÒ¹Ó°Ôº has provided me information explaining the risks of meningococcal disease and) Tj 0 -11.001 Td (the effectiveness and availability of the vaccine. I understand that Missouri law ) Tj (Section 174.335) Tj ( requires all students who reside in) Tj 0 -11.001 Td (on-campus housing to have received the meningococcal conjugate vaccine unless a signed statement of medical or religious exemption is) Tj 0 -11.001 Td (on file with the institution's administration.) Tj 0 -1.675 Td 0 -20.327 Td (A student shall be exempt from the immunization requirement for one of two reasons:) Tj 0 -11.001 Td (1\) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health) Tj 0 -11.001 Td (or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.) Tj 0 -11.001 Td (2\) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.) Tj 0 -1.675 Td 0 -20.327 Td /F3 10 Tf (Please submit the exemption request documentation with this completed form.) Tj ET 0 J 550.777 282.444 m 580.768 282.444 l S 0 J 29.798 271.443 m 62.311 271.443 l S BT /F2 10 Tf 29.798 294.72 Td (I am the parent or legal guardian of . The ÎçÒ¹Ó°Ôº has provided me information explaining the) Tj 0 -11.001 Td (risks of meningococcal disease and I am aware of the effectiveness and availability of the vaccine. I understand that Missouri law ) Tj (Section) Tj 0 -11.001 Td (174.335) Tj ( requires all students who reside in on-campus housing to have received the meningococcal conjugate vaccine unless a signed) Tj 0 -11.001 Td (statement of medical or religious exemption is on file with the institution's administration.) Tj 0 -1.675 Td 0 -20.327 Td (A student shall be exempt from the immunization requirement for one of two reasons:) Tj 0 -11.001 Td (1\) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health) Tj 0 -11.001 Td (or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.) Tj 0 -11.001 Td (2\) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.) Tj 0 -1.675 Td 0 -20.327 Td /F3 10 Tf (Please submit the exemption request documentation with this completed form.) 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