ES LT Medical acknowledgement form

Dear Parent: Thank you for enrolling your student in an EF Language Travel course to New York Residence. New York State Public Health Law requires overnight children’s camps to distribute information about meningococcal disease and vaccination to all campers who attend camp for 7 or more nights.

We are required to maintain a record of the following for each student:  A response to receipt of meningococcal disease and vaccine information  A record of meningococcal meningitis immunization; OR  An acknowledgement of meningococcal disease risks and refusal of meningococcal meningitis immunization In order for us to comply, please complete the following acknowledgments: 1. Sign below acknowledging that you have received and read this information.

2. Attach a record of meningococcal meningitis immunization OR sign the portion of the form refusing meningococcal meningitis immunization.

We encourage you to carefully review the Meningococcal Disease Fact Sheet, which can be found on the New York State Department of Health website at http://www.health.ny.gov/publications/2168.pdf.

If you have any questions, please feel free to contact me.

Yours sincerely,

Lars Ahlqvist Vice President, EF Language Travel

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 (7) or more consecutive nights, complete and return the following form to the camp.

Information Receipt Acknowledgement: Check and sign below □

I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine.

Meningococcal Meningitis Immunization: Check one and sign below □

I have I have decided that my child will not obtain immunization against meningococcal disease.

□ My child has received meningococcal immunization (Menactra or Menveo) within the past 10 years and I have attached a record.

Signed: ____________________________________________ (Parent / Guardian)

Camper’s Name: _____________________________________

Date: _____________________

Date of Birth: _______________

Mailing Address: __________________________________________________________________

Parent/Guardian’s E-mail Address (optional): ____________________________________________