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February 2017 COPY ONTO YOUR CHILDREN’S CAMP LETTERHEAD SAMPLE MENINGOCOCCAL MENINGITIS VACCINATION RESPONSE FORM New York State Public Health Law requires that a parent or guardian of campers who attend an overnight children’s camp for seven or more consecutive nights, complete and return the following form to the camp. Check one box and sign below. □ My child has received meningococcal immunization (Menactra or Menveo) within the past 10 years. Date received: [Note: The Centers for Disease Control and Prevention recommend two doses of MenACWY vaccine (Brand names: Menactra, Menveo) for all adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at 16 years of age. Adolescents in this age group with HIV infection should get three doses: 2 doses at least 8 weeks apart at 11 or 12 years of age, plus a booster dose at 16 years of age. If the first dose (or series) is given between 13 and 15 years of age, the booster should be given between 16 and 18 years of age. If the first dose (or series) is given after the 16th birthday, a booster is not needed. Young adults aged 16 through 23 years may choose to receive the Meningococcal B vaccine series (Brand names: Trumenba, Bexsero). Parents/guardians should discuss the Meningococcal B vaccine with a healthcare provider.] □ I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that my child will not obtain immunization against meningococcal disease. Signed: Date: (Parent / Guardian) Camper’s Name: Date of Birth: Mailing Address: Parent/Guardian’s E-mail Address (optional):