%PDF-1.3
%âãÏÓ
1 0 obj
<<
/Producer (OmniForm Converter for PDF)
/Creator (OmniForm Premium)
>>
endobj
4 0 obj
[ /PDF /Text ] 
endobj
6 0 obj
<< /Length 7 0 R >>
stream
BT
/F0 14 Tf
0 g 244.860 759.69 Td 92 Tz (University of ÑÇÖÞÓ°Ôº) Tj
/F1 16 Tf
-111.362 -19.928 Td 87 Tz (Meningococcal Vaccination Policy Compliance Form) Tj
/F1 12 Tf
-104.797 -73.318 Td 93 Tz (Student Information:) Tj
ET
.50 w
0 G
2 J
26.96 630.218 345.12 28.573 re
S
.75 w
2 J
372.078 630.218 109.68 28.573 re
S
.50 w
2 J
481.759 630.218 105.12 28.573 re
S
BT
/F0 8 Tf
376.401 649.412 Td 108 Tz (Student number) Tj
109.44 0 Td 111 Tz (Date of Birth) Tj
-283.442 -0.24 Td 114 Tz (First) Tj
140.882 -0.24 Td 117 Tz (M.) Tj
-314.16 -0.238 Td 102 Tz (Name: Last) Tj
/F1 14 Tf
140.987 -39.379 Td 92 Tz (For students who have received the vaccine) Tj
/F1 12 Tf
-140.882 -0.714 Td 86 Tz (Section 1) Tj
-0.479 -17.983 Td 103 Tz /F2 10 Tf (I have received a meningococcal vaccine after my 16th birthday. A copy of the required documentation is attached.) Tj
-0.479 -18 Td 100 Tz (Printed name of student:) Tj
ET
2 J
323.637 554.683 m
135.17 554.683 l
S
BT
361.287 555.871 Td 112 Tz (Date:) Tj
-333.45 -0.72 Td 101 Tz (Signature of student:) Tj
/F1 14 Tf
163.925 -22.096 Td 87 Tz (Waivers \(complete part A or B\)) Tj
/F1 12 Tf
-162 -1.338 Td 90 Tz (Section 2) Tj
28.74 -18.53 Td 85 Tz (To be completed by students 18 years of age or older) Tj
-28.74 0.383 Td 107 Tz (A.) Tj
/F2 10 Tf
0 -144.984 Td 102 Tz (Printed name of student:) Tj
ET
2 J
525.572 348.832 m
399.6 348.832 l
S
BT
365.28 349.061 Td (Date:) Tj
-335.52 0.094 Td 110 Tz (Signature of student:) Tj
/F1 12 Tf
36 -38.23 Td 91 Tz (For students under the age of 18) Tj
-36.72 -0.479 Td 88 Tz (B.) Tj
/F2 10 Tf
0.24 -143.92 Td 100 Tz (Printed name of parent/guardian:) Tj
ET
2 J
345.572 146.906 m
169.832 146.906 l
S
2 J
525.12 146.186 m
399.6 146.186 l
S
BT
364.683 148.334 Td 106 Tz (Date:) Tj
-333.989 -0.96 Td 100 Tz (Signature of parent/guardian:) Tj
/F1 12 Tf
114.267 -39.095 Td 85 Tz (Return completed form to one of the following campus addresses.) Tj
/F3 9 Tf
162 -12.790 Td 105 Tz (Rolla Campus) Tj
0.96 -8.88 Td 106 Tz /F2 9 Tf (Student Health Services) Tj
0.96 -8.88 Td 117 Tz (910 West 10th Street) Tj
-0.32 -8.88 Td 110 Tz (Rolla, MO 65409) Tj
/F3 9 Tf
147.447 27.615 Td 101 Tz (St Louis Campus) Tj
0 -8.64 Td 104 Tz /F2 9 Tf (University Health Services) Tj
0 -8.64 Td 121 Tz (One University Blvd.) Tj
0.921 -8.64 Td 101 Tz (131 Millennium Student Center) Tj
-0.201 -8.64 Td 100 Tz (St. Louis MO 63121-4499) Tj
-0.72 -8.64 Td 96 Tz (Fax: \(314\) 516-5988) Tj
/F3 9 Tf
-276.616 44.084 Td 104 Tz (Kansas City Campus) Tj
0 -9.119 Td 100 Tz /F2 9 Tf (UMKC Residential Life Office) Tj
0 -9.119 Td 125 Tz (5051 Oak Street) Tj
0 -9.119 Td 100 Tz (Kansas City, MO 64110) Tj
0 -0.726 Td /F3 9 Tf
-155.381 26.478 Td 99 Tz (Columbia Campus) Tj
0.96 -8.88 Td 101 Tz /F2 9 Tf (Student Health Center) Tj
0 -8.88 Td 115 Tz (1020 Hitt Street) Tj
-0.023 -9.397 Td 104 Tz (Columbia, MO 65201) Tj
0.479 0.952 Td 430.82 -26.836 Td 97 Tz (Phone: \(314\) 516-5671) Tj
-149.289 13.47 Td ( Phone: \(573\) 341-4284) Tj
-280.885 -5.7 Td (Phone: \(573\) 882-4661) Tj
154.885 6.265 Td 96 Tz (Phone: \(816\) 235-8840) Tj
ET
.68 w
0 0 1 RG
0 J
25.696 30.929 m
159.313 30.929 l
S
0 J
25.696 28.998 m
25.696 28.998 l
S
0 J
-6087355.313 790.852 m
-6087355.313 790.852 l
S
0 G
0 J
-6087355.313 790.852 m
-6086230.165 790.852 l
S
0 w
0 J
-6086230.165 792 m
-6086230.165 792 l
S
0 J
-6086230.165 792 m
-6086230.165 792 l
S
BT
0 0 1 rg 25.696 32.077 Td 113 Tz (www.studenthealth.missouri.edu) Tj
0 -1.93 Td 6087329.616 761.854 Td 16096 Tz 2001351.19 Tc 23408.856 Tw 0 g () Tj
ET
.68 w
0 0 1 RG
0 J
456.012 31.952 m
590.51 31.952 l
S
BT
0 0 1 rg 456.012 33.1 Td 100 Tz 0 Tc 0 Tw (http://www.umsl.edu/services/health/) Tj
ET
0 J
309.206 31.388 m
439.214 31.388 l
S
0 G
0 J
439.214 31.388 m
441.714 31.388 l
S
BT
306.96 32.536 Td ( ) Tj
(http://campus.mst.edu/studenthealth) Tj
0 g (/) Tj
ET
0 0 1 RG
0 J
177.36 28.363 m
276.900 28.363 l
S
BT
0 0 1 rg 177.36 29.511 Td 110 Tz (www.umkc.edu/housing/) Tj
/F0 8 Tf
0 g -154.8 -9.082 Td 90 Tz (UM 55 \(SEP14\) 9/14/14) Tj
ET
.50 w
0 G
2 J
522.125 554.502 m
396 554.502 l
S
2 J
345.6 348.832 m
169.2 348.832 l
S
BT
/F2 9 Tf
26.164 59.630 Td 101 Tz (Fax: \(573\) 884-8902) Tj
-0.003 -18.020 Td 90 Tz (Email: immunizations@health.missouri.edu) Tj
/F2 10 Tf
1.837 676.134 Td 100 Tz (P) Tj
/F2 11 Tf (lease return this form and the necessary documentation to the appropriate campus address as listed below. For additional) Tj
0 -11.001 Td (information on the meningococcal vaccine, see the following Centers for Disease Control \(CDC\) website:) Tj
0 -11.001 Td (http://www.cdc.gov/vaccines/hcp/vis/fis-statements/mening.html. If you do not have web access you may contact your) Tj
0 -11.001 Td (campus for information.) Tj
ET
.75 w
0 J
349.46 485.09 m
414.459 485.09 l
S
BT
/F2 10 Tf
29.798 497.367 Td (I am 18 years of age or older. The University of ÑÇÖÞÓ°Ôº has provided me information explaining the risks of meningococcal disease and) Tj
0 -11.001 Td (the effectiveness and availability of the vaccine. I understand that ÑÇÖÞÓ°Ôº law ) Tj
(Section 174.335) Tj
( requires all students who reside in) Tj
0 -11.001 Td (on-campus housing to have received the meningococcal conjugate vaccine unless a signed statement of medical or religious exemption is) Tj
0 -11.001 Td (on file with the institution's administration.) Tj
0 -1.675 Td 0 -20.327 Td (A student shall be exempt from the immunization requirement for one of two reasons:) Tj
0 -11.001 Td (1\) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health) Tj
0 -11.001 Td (or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.) Tj
0 -11.001 Td (2\) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.) Tj
0 -1.675 Td 0 -20.327 Td /F3 10 Tf (Please submit the exemption request documentation with this completed form.) Tj
ET
0 J
550.777 282.444 m
580.768 282.444 l
S
0 J
29.798 271.443 m
62.311 271.443 l
S
BT
/F2 10 Tf
29.798 294.72 Td (I am the parent or legal guardian of                                                   . The University of ÑÇÖÞÓ°Ôº has provided me information explaining the) Tj
0 -11.001 Td (risks of meningococcal disease and I am aware of the effectiveness and availability of the vaccine. I understand that ÑÇÖÞÓ°Ôº law ) Tj
(Section) Tj
0 -11.001 Td (174.335) Tj
( requires all students who reside in on-campus housing to have received the meningococcal conjugate vaccine unless a signed) Tj
0 -11.001 Td (statement of medical or religious exemption is on file with the institution's administration.) Tj
0 -1.675 Td 0 -20.327 Td (A student shall be exempt from the immunization requirement for one of two reasons:) Tj
0 -11.001 Td (1\) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health) Tj
0 -11.001 Td (or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.) Tj
0 -11.001 Td (2\) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.) Tj
0 -1.675 Td 0 -20.327 Td /F3 10 Tf (Please submit the exemption request documentation with this completed form.) Tj
/F2 9 Tf
277.163 -143.663 Td 106 Tz ( Email: mstshs@mst.edu) Tj
ET
.50 w
2 J
525.572 330.684 m
399.6 330.684 l
S
BT
/F2 10 Tf
365.28 330.914 Td 102 Tz (Date:) Tj
-335.52 0.094 Td 106 Tz (Signature of campus official:) Tj
ET
2 J
345.6 330.684 m
169.2 330.684 l
S
2 J
525.572 128.038 m
399.6 128.038 l
S
BT
364.56 128.361 Td 107 Tz (Date:) Tj
-334.8 0 Td 106 Tz (Signature of campus official:) Tj
ET
2 J
345.6 128.038 m
169.2 128.038 l
S
2 J
325.267 572.649 m
136.8 572.649 l
S
2 J
345.6 366.979 m
169.2 366.979 l
S
2 J
296.442 294.389 m
176.4 294.389 l
S
2 J
344.475 166.056 m
169.260 166.056 l
S
endstream
endobj
7 0 obj
7925 
endobj
5 0 obj
<<
/Type /Page
/Parent 3 0 R
/Resources << /ProcSet [ /PDF /Text ] /Font << /F0 8 0 R /F1 11 0 R /F2 14 0 R /F3 17 0 R >> >>
/MediaBox [ 0 0 612 792 ]
/Contents 6 0 R
/Annots 35 0 R
>>
endobj
26 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 27 630 197 644 ]
/T (Name_Last)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
27 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 200 630 336 644 ]
/T (First)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
28 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 338 630 370 644 ]
/T (FillText8)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
29 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 374 630 481 644 ]
/T (FillText9)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
/Q 1
>>
endobj
30 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 482 630 586 644 ]
/T (FillText10)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
/Q 1
>>
endobj
31 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 137 573 325 586 ]
/T (FillText5)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
32 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 169 367 346 380 ]
/T (FillText6)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
33 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 176 294 296 308 ]
/T (I_am_the_parent_or_legal_guardian_of)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
34 0 obj
<< 
/Type /Annot
/Subtype /Widget
/Rect [ 169 166 344 179 ]
/T (Printed_name_of_parentguardian)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
20 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 26 28 26 38 ]
/A 37 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
37 0 obj
<< 
/S /URI
/URI (http://www.studenthealth.missouri.edu)
>>
endobj
21 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 0 790 0 800 ]
/A 38 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
38 0 obj
<< 
/S /URI
/URI (http://www.studenthealth.missouri.edu)
>>
endobj
22 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 25 28 161 41 ]
/A 39 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
39 0 obj
<< 
/S /URI
/URI (http://www.studenthealth.missouri.edu)
>>
endobj
23 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 456 31 591 41 ]
/A 40 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
40 0 obj
<< 
/S /URI
/URI (http://www.umsl.edu/services/health/)
>>
endobj
24 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 307 31 439 41 ]
/A 41 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
41 0 obj
<< 
/S /URI
/URI (http://studenthealth.mst.edu)
>>
endobj
25 0 obj
<< 
/Type /Annot
/Subtype /Link
/Rect [ 177 28 277 38 ]
/A 42 0 R
/Border [ 0 0 0 ]
/H /N
>>
endobj
42 0 obj
<< 
/S /URI
/URI (http://www.umkc.edu/studenthealth)
>>
endobj
35 0 obj
[
20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 
28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 
]
endobj
43 0 obj
<<
/AcroForm 0.8
/DR 44 0 R
/DA (/TiRo 10 Tf 0 g)
/Fields
[
26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 
34 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 
]
>>
endobj
44 0 obj
<< 
/Font << /TiRo 36 0 R >>
>>
endobj
36 0 obj
<< 
/Type /Font
/Subtype /Type1
/Name /TiRo
/BaseFont /Times-Roman
/FirstChar 32
/LastChar 255
/Encoding 45 0 R
>>
endobj
45 0 obj
<< 
/Type /Encoding
/Differences [
24 /breve /caron /circumflex /dotaccent /hungarumlaut /ogonek /ring
/tilde 39 /quotesingle 96 /grave 128 /bullet /dagger /daggerdbl
/ellipsis /emdash /endash /florin /fraction /guilsinglleft /guilsinglright
/minus /perthousand /quotedblbase /quotedblleft /quotedblright /quoteleft
/quoteright /quotesinglbase /trademark /fi /fl /Lslash /OE /Scaron
/Ydieresis /Zcaron /dotlessi /lslash /oe /scaron /zcaron 160 /Euro
164 /currency 166 /brokenbar 168 /dieresis /copyright /ordfeminine
172 /logicalnot /.notdef /registered /macron /degree /plusminus
/twosuperior /threesuperior /acute /mu 183 /periodcentered /cedilla
/onesuperior /ordmasculine 188 /onequarter /onehalf /threequarters
192 /Agrave /Aacute /Acircumflex /Atilde /Adieresis /Aring /AE /Ccedilla
/Egrave /Eacute /Ecircumflex /Edieresis /Igrave /Iacute /Icircumflex
/Idieresis /Eth /Ntilde /Ograve /Oacute /Ocircumflex /Otilde /Odieresis
/multiply /Oslash /Ugrave /Uacute /Ucircumflex /Udieresis /Yacute
/Thorn /germandbls /agrave /aacute /acircumflex /atilde /adieresis
/aring /ae /ccedilla /egrave /eacute /ecircumflex /edieresis /igrave
/iacute /icircumflex /idieresis /eth /ntilde /ograve /oacute /ocircumflex
/otilde /odieresis /divide /oslash /ugrave /uacute /ucircumflex
/udieresis /yacute /thorn /ydieresis
]
>>
endobj
8 0 obj
<< 
/Type /Font
/Subtype /TrueType
/Name /F0
/BaseFont /Arial
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 9 0 R
/Widths 10 0 R
>>
endobj
9 0 obj
<< 
/Type /FontDescriptor
/Flags 32
/FontName /Arial
/FontBBox [ -665 -325 2000 1006 ]
/MissingWidth 750
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 905
/XHeight 633
/Ascent 905
/Descent -212
/Leading 150
/MaxWidth 2665
/AvgWidth 441
>>
endobj
10 0 obj
[
750 750 278 278 355 556 556 889 667 191 333 333 389 584 278 333 
278 278 556 556 556 556 556 556 556 556 556 556 278 278 584 584 
584 556 1015 667 667 722 722 667 611 778 722 278 500 667 556 833 
722 778 667 778 722 667 611 722 667 944 667 667 611 278 278 278 
469 556 333 556 556 500 556 556 278 556 556 222 222 500 222 833 
556 556 556 556 333 500 278 556 500 722 500 500 500 334 260 334 
584 750 556 750 222 556 333 1000 556 556 333 1000 667 333 1000 750 
611 750 750 222 222 333 333 350 556 1000 333 1000 500 333 944 750 
500 667 278 333 556 556 556 556 260 556 333 737 370 556 584 333 
737 552 400 549 333 333 333 576 537 333 333 333 365 556 834 834 
834 611 667 667 667 667 667 667 1000 722 667 667 667 667 278 278 
278 278 722 722 778 778 778 778 778 584 778 722 722 722 722 667 
667 611 556 556 556 556 556 556 889 500 556 556 556 556 278 278 
278 278 556 556 556 556 556 556 556 549 611 556 556 556 556 500 
556 500 
]
endobj
11 0 obj
<< 
/Type /Font
/Subtype /TrueType
/Name /F1
/BaseFont /Arial,Bold
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 12 0 R
/Widths 13 0 R
>>
endobj
12 0 obj
<< 
/Type /FontDescriptor
/Flags 32
/FontName /Arial,Bold
/FontBBox [ -628 -376 2000 1018 ]
/MissingWidth 750
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 905
/XHeight 633
/Ascent 905
/Descent -212
/Leading 150
/MaxWidth 2628
/AvgWidth 479
>>
endobj
13 0 obj
[
750 750 278 333 474 556 556 889 722 238 333 333 389 584 278 333 
278 278 556 556 556 556 556 556 556 556 556 556 333 333 584 584 
584 611 975 722 722 722 722 667 611 778 722 278 556 722 611 833 
722 778 667 778 722 667 611 722 667 944 667 667 611 333 278 333 
584 556 333 556 611 556 611 556 333 611 611 278 278 556 278 889 
611 611 611 611 389 556 333 611 556 778 556 556 500 389 280 389 
584 750 556 750 278 556 500 1000 556 556 333 1000 667 333 1000 750 
611 750 750 278 278 500 500 350 556 1000 333 1000 556 333 944 750 
500 667 278 333 556 556 556 556 280 556 333 737 370 556 584 333 
737 552 400 549 333 333 333 576 556 333 333 333 365 556 834 834 
834 611 722 722 722 722 722 722 1000 722 667 667 667 667 278 278 
278 278 722 722 778 778 778 778 778 584 778 722 722 722 722 667 
667 611 556 556 556 556 556 556 889 556 556 556 556 556 278 278 
278 278 611 611 611 611 611 611 611 549 611 611 611 611 611 556 
611 556 
]
endobj
14 0 obj
<< 
/Type /Font
/Subtype /TrueType
/Name /F2
/BaseFont /TimesNewRoman
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 15 0 R
/Widths 16 0 R
>>
endobj
15 0 obj
<< 
/Type /FontDescriptor
/Flags 34
/FontName /TimesNewRoman
/FontBBox [ -568 -307 2000 1007 ]
/MissingWidth 778
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 891
/XHeight 623
/Ascent 891
/Descent -216
/Leading 149
/MaxWidth 2568
/AvgWidth 401
>>
endobj
16 0 obj
[
778 778 250 333 408 500 500 833 778 180 333 333 500 564 250 333 
250 278 500 500 500 500 500 500 500 500 500 500 278 278 564 564 
564 444 921 722 667 667 722 611 556 722 722 333 389 722 611 889 
722 722 556 722 667 556 611 722 722 944 722 722 611 333 278 333 
469 500 333 444 500 444 500 444 333 500 500 278 278 500 278 778 
500 500 500 500 333 389 278 500 500 722 500 500 444 480 200 480 
541 778 500 778 333 500 444 1000 500 500 333 1000 556 333 889 778 
611 778 778 333 333 444 444 350 500 1000 333 980 389 333 722 778 
444 722 250 333 500 500 500 500 200 500 333 760 276 500 564 333 
760 500 400 549 300 300 333 576 453 333 333 300 310 500 750 750 
750 444 722 722 722 722 722 722 889 667 611 611 611 611 333 333 
333 333 722 722 722 722 722 722 722 564 722 722 722 722 722 722 
556 500 444 444 444 444 444 444 667 444 444 444 444 444 278 278 
278 278 500 500 500 500 500 500 500 549 500 500 500 500 500 500 
500 500 
]
endobj
17 0 obj
<< 
/Type /Font
/Subtype /TrueType
/Name /F3
/BaseFont /TimesNewRoman,Bold
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 18 0 R
/Widths 19 0 R
>>
endobj
18 0 obj
<< 
/Type /FontDescriptor
/Flags 34
/FontName /TimesNewRoman,Bold
/FontBBox [ -558 -307 2000 1026 ]
/MissingWidth 778
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 891
/XHeight 623
/Ascent 891
/Descent -216
/Leading 149
/MaxWidth 2558
/AvgWidth 427
>>
endobj
19 0 obj
[
778 778 250 333 555 500 500 1000 833 278 333 333 500 570 250 333 
250 278 500 500 500 500 500 500 500 500 500 500 333 333 570 570 
570 500 930 722 667 722 722 667 611 778 778 389 500 778 667 944 
722 778 611 778 722 556 667 722 722 1000 722 722 667 333 278 333 
581 500 333 500 556 444 556 444 333 500 556 278 333 556 278 833 
556 500 556 556 444 389 333 556 500 722 500 500 444 394 220 394 
520 778 500 778 333 500 500 1000 500 500 333 1000 556 333 1000 778 
667 778 778 333 333 500 500 350 500 1000 333 1000 389 333 722 778 
444 722 250 333 500 500 500 500 220 500 333 747 300 500 570 333 
747 500 400 549 300 300 333 576 540 333 333 300 330 500 750 750 
750 500 722 722 722 722 722 722 1000 722 667 667 667 667 389 389 
389 389 722 722 778 778 778 778 778 570 778 722 722 722 722 722 
611 556 500 500 500 500 500 500 722 444 444 444 444 444 278 278 
278 278 500 556 500 500 500 500 500 549 500 556 556 556 556 500 
556 500 
]
endobj
3 0 obj
<< 
/Type /Pages 
/Count 1 
/Kids [ 5 0 R ]
/MediaBox [ 0 0 612 792 ]
>>
endobj
2 0 obj
<< 
/Type /Catalog 
/Pages 3 0 R 
/AcroForm 43 0 R
>> 
endobj
xref
0 46
0000000000 65535 f
0000000015 00000 n
0000018220 00000 n
0000018132 00000 n
0000000103 00000 n
0000008133 00000 n
0000000134 00000 n
0000008112 00000 n
0000012587 00000 n
0000012759 00000 n
0000013013 00000 n
0000013959 00000 n
0000014138 00000 n
0000014398 00000 n
0000015343 00000 n
0000015525 00000 n
0000015788 00000 n
0000016730 00000 n
0000016917 00000 n
0000017185 00000 n
0000009674 00000 n
0000009857 00000 n
0000010040 00000 n
0000010224 00000 n
0000010408 00000 n
0000010584 00000 n
0000008333 00000 n
0000008475 00000 n
0000008614 00000 n
0000008757 00000 n
0000008905 00000 n
0000009054 00000 n
0000009197 00000 n
0000009340 00000 n
0000009510 00000 n
0000010765 00000 n
0000011128 00000 n
0000009781 00000 n
0000009964 00000 n
0000010148 00000 n
0000010333 00000 n
0000010517 00000 n
0000010693 00000 n
0000010892 00000 n
0000011080 00000 n
0000011259 00000 n
trailer
<<
/Size 46 
/Root 2 0 R
/Info 1 0 R
>>
startxref
18291
%%EOF2 0 obj
<</AcroForm 43 0 R/Lang(en)/Metadata 46 0 R/Pages 3 0 R/Type/Catalog>>
endobj
43 0 obj
<</DA(/TiRo 10 Tf 0 g)/DR 44 0 R/Fields[26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R]>>
endobj
44 0 obj
<</Encoding<</PDFDocEncoding 49 0 R>>/Font<</Helv 47 0 R/TiRo 36 0 R/ZaDb 48 0 R>>>>
endobj
46 0 obj
<</Length 4162/Subtype/XML/Type/Metadata>>stream
<?xpacket begin="" id="W5M0MpCehiHzreSzNTczkc9d"?>
<x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="Adobe XMP Core 4.2.1-c043 52.372728, 2009/01/18-15:08:04        ">
   <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#">
      <rdf:Description rdf:about=""
            xmlns:xmp="http://ns.adobe.com/xap/1.0/">
         <xmp:CreatorTool>OmniForm Premium</xmp:CreatorTool>
         <xmp:ModifyDate>2014-09-12T16:24:43-05:00</xmp:ModifyDate>
         <xmp:CreateDate>2014-09-12T16:24:43-05:00</xmp:CreateDate>
         <xmp:MetadataDate>2014-09-12T16:24:43-05:00</xmp:MetadataDate>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:pdf="http://ns.adobe.com/pdf/1.3/">
         <pdf:Producer>OmniForm Converter for PDF</pdf:Producer>
         <pdf:Keywords>Meningococcal Vaccination Policy Compliance Form</pdf:Keywords>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:dc="http://purl.org/dc/elements/1.1/">
         <dc:format>application/pdf</dc:format>
         <dc:title>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">University of ÑÇÖÞÓ°Ôº System - Meningococcal Vaccination Policy Compliance Form</rdf:li>
            </rdf:Alt>
         </dc:title>
         <dc:description>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Meningococcal Vaccination Policy Compliance Form</rdf:li>
            </rdf:Alt>
         </dc:description>
         <dc:creator>
            <rdf:Bag>
               <rdf:li>ParksC</rdf:li>
            </rdf:Bag>
         </dc:creator>
         <dc:subject>
            <rdf:Bag>
               <rdf:li>Meningococcal Vaccination Policy Compliance Form</rdf:li>
            </rdf:Bag>
         </dc:subject>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/">
         <xmpMM:DocumentID>uuid:312bbaa5-512e-4d2f-842a-f7e77fab3fba</xmpMM:DocumentID>
         <xmpMM:InstanceID>uuid:f40885cc-040d-4fb5-9c7c-9d2db1580f94</xmpMM:InstanceID>
      </rdf:Description>
   </rdf:RDF>
</x:xmpmeta>
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    
                           
<?xpacket end="w"?>
endstream
endobj
47 0 obj
<</BaseFont/Helvetica/Encoding 49 0 R/Name/Helv/Subtype/Type1/Type/Font>>
endobj
48 0 obj
<</BaseFont/ZapfDingbats/Name/ZaDb/Subtype/Type1/Type/Font>>
endobj
49 0 obj
<</Differences[24/breve/caron/circumflex/dotaccent/hungarumlaut/ogonek/ring/tilde 39/quotesingle 96/grave 128/bullet/dagger/daggerdbl/ellipsis/emdash/endash/florin/fraction/guilsinglleft/guilsinglright/minus/perthousand/quotedblbase/quotedblleft/quotedblright/quoteleft/quoteright/quotesinglbase/trademark/fi/fl/Lslash/OE/Scaron/Ydieresis/Zcaron/dotlessi/lslash/oe/scaron/zcaron 160/Euro 164/currency 166/brokenbar 168/dieresis/copyright/ordfeminine 172/logicalnot/.notdef/registered/macron/degree/plusminus/twosuperior/threesuperior/acute/mu 183/periodcentered/cedilla/onesuperior/ordmasculine 188/onequarter/onehalf/threequarters 192/Agrave/Aacute/Acircumflex/Atilde/Adieresis/Aring/AE/Ccedilla/Egrave/Eacute/Ecircumflex/Edieresis/Igrave/Iacute/Icircumflex/Idieresis/Eth/Ntilde/Ograve/Oacute/Ocircumflex/Otilde/Odieresis/multiply/Oslash/Ugrave/Uacute/Ucircumflex/Udieresis/Yacute/Thorn/germandbls/agrave/aacute/acircumflex/atilde/adieresis/aring/ae/ccedilla/egrave/eacute/ecircumflex/edieresis/igrave/iacute/icircumflex/idieresis/eth/ntilde/ograve/oacute/ocircumflex/otilde/odieresis/divide/oslash/ugrave/uacute/ucircumflex/udieresis/yacute/thorn/ydieresis]/Type/Encoding>>
endobj
50 0 obj
<</Author(ParksC)/CreationDate(D:20140912162443-05'00')/Creator(OmniForm Premium)/Keywords(Meningococcal Vaccination Policy Compliance Form)/ModDate(D:20140912162443-05'00')/Producer(OmniForm Converter for PDF)/Subject(Meningococcal Vaccination Policy Compliance Form)/Title(University of ÑÇÖÞÓ°Ôº System - Meningococcal Vaccination Policy Compliance Form)>>
endobj
xref
0 1
0000000000 65535 f
2 1
0000019290 00000 n
43 2
0000019376 00000 n
0000019540 00000 n
46 5
0000019641 00000 n
0000023881 00000 n
0000023971 00000 n
0000024048 00000 n
0000025240 00000 n
trailer
<</Size 51/Root 2 0 R/Info 50 0 R/ID[<5C8BB73F6222294BBA694C94C07E6FDC><5C8BB73F6222294BBA694C94C07E6FDC>]/Prev 18291>>
startxref
25615
%%EOF