Meningitis Form

In Compliance with Oklahoma Statutes, Title 70 §3243 Certification of Meningococcal Compliance Oklahoma Statutes, Title 70 §3243, requires that all students who are first time enrollees in any public or private postsecondary educational institution in this state and who reside in on-campus student housing shall be vaccinated against meningococcal disease. Institutions of higher education must provide the student or the student’s parents or other legal representative detailed information on the risks associated with meningococcal disease and on the availability and effectiveness of any vaccine. The statute permits the student or, if the student is a minor, the student’s parent or other legal representative, to sign a written waiver stating that the student has received and reviewed the information provided on the risks associated with meningococcal disease and on the availability and effectiveness of any vaccine, and has chosen not to be or not to have the student vaccinated.

Student Information

When student is under 18 years of age, the following must also be completed: As the parent, guardian or other legal representative, I certify that the student named above is a minor and that I have received and reviewed the information provided and that I have chosen not to have the student vaccinated against meningococcal disease.


 Check this box as your electronic signature.

* By selecting above that I have chosen not to be vaccinated against meningococcal disease, with this waiver, I seek exemption from this requirement. I voluntarily agree to release, discharge, indemnify and hold harmless Northwestern Oklahoma State University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my decision not to be immunized against meningitis. By not being immunized I realize if there is a case of meningitis on campus I will be required to leave campus and remain off campus until it is deemed safe to return.

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Phone: (580) 327-1700

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