Updated 5.25.16 bc
Name of student: _______________________________________ T#: _______________ Term: ___________
(Last) (First) (MI)
Students who are enrolled in ONLY online classes, including TTU online and TN eCampus (formerly RODP) courses,
are exempt from immunization requirements. To request this exemption, complete this form and fax, scan/email, mail,
or deliver to the Office of the Registrar. This form must be completed each semester for which the exemption is
being requested.
I affirm that I am only registered for online courses at TTU during the semester as stated above. I understand that I will need to
complete a new form each semester to continue to be exempt from all the immunization requirements that are related to full-time
enrollment.
Student Signature: _______________________________________ Date: ________________
Immunization Exemption for Full-Time Distance Learning Students
Please return completed form to:
Registration Center │Tennessee Technological University │Derryberry Hall 121
TTU Box 5026
Cookeville, TN 38505
Fax: (931) 372.6111
