Meningitis Form - Non SSO

First Name

Last Name

Middle Name

SJC ID# (Include G in ID):  Example:     GXXXXXXXX

Date of Birth

Telephone

Email Address

Please select the option that will most accurately describe your status at the time you plan to enroll in classes.

Date Submitted

I have received the Bacterial Meningitis Vaccine or booster within the last 5 years and am attaching an official vaccination record.

 

         

I am enrolling ONLY in distance learning courses that are taught 100 percent online. (Session Description of (Online-100 percent Computer/Web).
I understand that I must request this temporary waiver each semester and when I am no longer enrolled in only 100 percent Online Distance Learning classes, I must comply with the Meningitis requirement.

I am declaring a temporary waiver due to a medical exemption affidavit or certificate signed by a physician who is duly registered and licensed to practice medicine in the U.S., in which it is stated that, in the physician’s opinion, the vaccination required would be injurious to the health and well-being of the student. I understand that when the affidavit is no longer valid, I must comply with the Meningitis requirement.

 

By entering my initials I attest that the information entered and uploaded is authentic, correct and reflects the entered student's name on this form.