Vaccination Acknowledgement

The following waiver must be filled out by a Parent and/or Guardian for any teen prior to attending a BBYO chapter or regional overnight program. Teens will not be allowed to attend a BBYO overnight program without the submission of a waiver.

Name of Participant: Teen First Name*

Teen Last Name*

Teen Email*

Teen Cell Phone*

Teen Gender*

Teen Graduation Year*

Teen Zip Code*

Parent Email*

Parent Cell Phone*

Parent Zip Code*

I confirm that my teen is fully vaccinated with the following vaccines. I understand I will have to present documentation if asked by BBYO. I understand falsifying this statement will result my teen being removed from BBYO

Tdap (Diphtheria, Tetanus and Pertussis)
IPV (Poliovirus)
HIB (Haemophilus influenza type b bacteria)
PCV 13 (Pneumococcal) vaccine or PCV 23
MMR (Measles, Mumps, Rubella) or serologic evidence of immunity
Varicella vaccine (Chicken Pox), or serologic or historical evidence of immunity
Menactra (Meningococcal disease / Meningitis)

Signature of Parent/Guardian:*