CO RequestJC

A separate, signed application must be submitted for each individual to receive an exemption from Texas meningococcal vaccination requirements. This form is for official use only and is not valid if photocopied. You must have a working printer to complete this transaction.

Please complete the required fields in Sections A and B: first name, last name, date of birth (in MM/DD/YYYY format), and zip (postal) code. Select your community college from the drop-down menu in Section C. Use the scroll bar to the right to read the Risks and Benefits of Meningococcal Vaccination. After reading the Risks and Benefits, check the box certifying the information supplied is correct. After this, the Print button at the bottom of this form will become enabled. Clicking it will create your exemption, which you will print and provide to your community college.

(A) Individual’s Full Name and Date of Birth:

First Name Middle Name Last Name

Date of Birth

(B) Address:

Street Apt./Suite City

State Zip Code

(C) Community college/public junior college:
NOTE: This list may not include your individual community college campus. Please select your facility's community college system or district, if applicable.

Risks and Benefits of Meningococcal Vaccination

Vaccine-Preventable Disease	Effectiveness of Vaccine	Possible Side Effects of Vaccination
Meningococcal disease is an acute, potentially severe illness that most often causes meningitis, an infection of the spinal fluid and the fluid that surrounds the brain. It leads to sudden onset of fever, headache, and stiff neck and is usually accompanied by nausea, vomiting, light sensitivity, and altered mental status. Less commonly, it can cause pneumonia, arthritis, and ear/throat infections. Meningococcal disease can result in hearing loss, nervous system problems, seizures, strokes, loss of limbs (arms, legs), and even death.	A protective level of antibody is usually achieved within 7 – 10 days of vaccination. The vaccines protect about 90% of individuals who get them.	The most common side effects are redness or pain at the injection site lasting 1– 2 days, headache, and fatigue. Serious allergic reactions are very rare.

I have read and I understand the Risks and Benefits of Meningococcal Vaccination information. I understand the risks of not vaccinating self/child. I further understand that self/child may be excluded from school attendance in times of emergency or epidemic declared by the Commissioner of Public Health.

I do NOT want the individual named above to receive the meningococcal vaccine for reasons of conscience, which may include a religious belief.

I certify that I am the student named above, or the parent or legal guardian of the student named above, and that the information provided herein is true and correct.

Exemption from Meningococcal Vaccination Requirements
for Reasons of Conscience

Denotes required field

Exemption from Meningococcal Vaccination Requirements for Reasons of Conscience

Denotes required field

Exemption from Meningococcal Vaccination Requirements
for Reasons of Conscience