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Please CHECK ONE BOX and SIGN BELOW. My child has had the meningococcal meningitis immunization Menomune within the past 10 years. I understand the risks of not receiving the vaccine. I have decided that my child will not obtain immunization against meningococcal meningitis disease. Date received I have read or have had explained to me the information regarding meningococcal meningitis disease. This authorization shall remain effective until August 31 2013 unless sooner revoked in writing...
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