Meningococcal Vaccine
Pre-Order/ Pre-Pay Program

 

Welcome to Juniata College!

By Pre-ordering and Pre-Paying for the meningococcal vaccine, MenactraT, meningococcal (Groups A, C, Y and W-135) polysaccharide diphtheria toxoid conjugate vaccine, you are guaranteed a reserved dose at the first day of your Summer Orientation (times and location to be announced).

 
Please print -

Last Name: __________________________________________

First Name: __________________________________________

Date Attending Orientation: _________________________________________________________

Pre-Order/Pre-Pay: $95.00

Method of Payment:

     Cash (   )

     Check (   )    Check #________

 

I understand that Pre-Ordering and Pre-Paying for the meningococcal vaccine, MenactraT, will only guarantee me a reserved dose at the Summer Orientation, time and location to be announced.  In the event that I cannot arrange to attend the scheduled time, I understand that I cannot be guaranteed to receive the vaccine, however I can try to schedule an appointment at the Health Center at the start of the academic year.

Students Signature: _____________________________________ Date: ____________

Parent/Guardian Signature: _______________________________________ Date: ____________
                                       (Parent or Guardian if student is under 18 years of age)

 

Please send payment by June 1, 2008 to:                   

Juniata College Health Center
Attention - Connie Peters

1700 Moore Street

Huntingdon, PA  16652