Hepatitis B Declination Form – Emergency Medical Services University, LLC

Hepatitis B Declination Form

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I understand that due to my risk of exposure to blood or other potentially infectious materials I could potentially acquire the Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B Vaccine prior to admission into the program.

Additionally, I understand that enrollment in this program is optional and that although it is recommended to obtain or otherwise receive the Hepatits B vaccine, I hereby decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I am at risk of acquiring hepatitis B, a serious disease.

I hereby indemnify and hold harmless EMS University and its employees relating to my choice to not receive the vaccination. If in the future, I want to be vaccinated with Hepatitis B vaccine, I have the option to do so, but shall pay for the vaccination myself.

Dated:

Student Dated: Signature:

Name

First

Last

Student ID:

Mandatory! Please enter the correct number to receive credit. EMT student ID's are usually in this format: 123456FT-01 and are located in your email. If you do not know the number, meet Customer Service in Live Chat or call (800) 728-0209.

Signature:

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