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February 2018 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. The Centers for Disease Control and Prevention recommends two doses of MenACWY vaccine (Brand names: Menactra, Menveo) for all healthy adolescents 11 through 18 years of age: the first dose is given at 11 or 12 years of age, with a booster dose at 16 years of age. Children and adolescents with certain medical conditions may need to begin the MenACWY series at a younger age and/or receive additional doses. Consult with your child’s healthcare provider regarding any medical conditions they may have. If the first dose 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 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. Check one box and sign below. □ I have received and reviewed the information regarding meningococcal meningitis. My child has received meningococcal immunization (Menactra or Menveo) within the past 10 years. Date received: OR I have received and reviewed the information regarding meningococcal meningitis. I understand the risks of meningococcal meningitis and the benefits of immunization at the recommended ages. □ I have decided that my child, who is younger than 11 years of age, will not obtain immunization against meningococcal disease at this time; or □ I have decided that my child, who is 11 years of age or older, will not obtain immunization against meningococcal disease at this time. Signed: Date: (Parent / Guardian) Camper’s Name: Date of Birth: Mailing Address: Parent/Guardian’s E-mail Address (optional):