Department of Residence Life
1600 Maple Street
Golden, Co. 80401-1887

IMPORTANT INFORMATION
(Please return this form with your Residence Life housing contract)

A Meningococcal Vaccine is available for protection against most strains of the bacteria that cause
meningitis. Meningitis is the inflammation of the covering of the brain and spinal cord that is fatal
in 10-15 percent of the cases. Although the disease is rare, college students living in the Residence
Halls and individuals with weak immune systems can be more susceptible to the disease. The
immunization requires one injection in the arm and is 85-90 percent protective against strains A, C,
Y and W-135, but not type B. Most meningococcal diseases in the U. S. are caused by types B or C.
A booster is recommended after three to five years if still at higher risk.

VERIFICATION OF MENINGOCOCCAL VACCINE

In accordance with Colorado law, the following verifies the date that:

Name: _______________________________________________ received meningococcal vaccine.

Date of birth: ______________________ Date of vaccine given: ____________________

CSM School ID# (CWID#): _______________________________

Signature of medical provider: ___________________________________ (or attach documentation)



ACKNOWLEGEMENT OF RECEIPT OF INFORMATION/
WAIVER OF IMMUNIZATION AGAINST MENINGOCOCCAL DISEASE

This section is to be filled out by student and parent/guardian, waiving the vaccine only.

I have read the information regarding bacterial meningitis and I do not wish to receive the meningococcal
vaccine. I voluntarily agree to release, discharge, indemnify and hold harmless the State of Colorado,
Colorado School of Mines, its officers, employees and agents from any and all costs, liabilities, expenses,
claims, demands, or causes of action on account of any loss or personal injury that might result from not
receiving the meningococcal vaccine.

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: ___________________

Name of Student (Printed) ___________________________________ CWID#__________________

If the student is under age 18, a parent/guardian must also sign this waiver.

Signature of Parent/Guardian____________________________________Date: ________________

11/12

CSM


Name of Parent/Guardian (Printed) ____________________________________________________
11/12

CSM