1 Start 2 Complete Name of Applicant * Sex * Male Female FSCC Sport or Program * City * State * ZIP Code * Medical Conditions staff should be aware of Medications Allergic reactions to IN CASE OF EMERGENCY CONTACT: Name * City State ZIP Code MUMPS & MEASLES Have you had at least one MMR vaccination? * Yes No Have you had the measles? * Yes No MENINGITIS FSCC recommends that all students living in FSCC housing have a meningitis vaccination. Before a student can move into housing, he/she must provide a copy of his/her meningitis vaccination record or sign the waiver below. Have you had a meningitis vaccination? * Yes No If YES, a copy of your meningitis vaccination record must be on file with FSCC. If NO, read and sign the following. I understand that meningitis is an infection that causes inflammation of the brain and spinal cord and can cause serious illness and permanent disabilities (such as deafness, limb amputation or death). Furthermore, I acknowledge that FSCC has recommended that I receive the meningitis vaccination. However, I do not choose to be vaccinated for this disease and release FSCC from any liability for illness or disabilities resulting from meningitis, should I contract the disease. Student Signature * Parent/Guardian Signature (unless over 17) Today's Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025
