Office of Admissions and Records
University of Nevada, Reno/MS 0120 - 775-784-4700 - Fax: 775-784-4283
Distance Education (Online) Request to Enroll with
Immunization Exemption
Students who plan on enrolling exclusively in Distance Education (Online) classes may request to enroll with an immunization
exemption available for specific online only classes. Please submit the completed and signed form to the Office of Admissions and
Records via the contact information on the bottom of this form. This policy is pursuant to NRS 441A.750, NRS 441A.755 & NRS 441A.120
Please note: Students requesting to be added into Distance Education (Online) classes with an immunization exemption may
not register for on-campus classes or use any University of Nevada, Reno on-campus facilities (for example: The Knowledge
Center, 365 Learning Testing Center, Lombardi Recreation, etc.). This exemption does not remove the immunization registration
hold from your record. Students requesting an exemption are not eligible to be place on waitlists for classes. Unless you submit
the requested immunizations you will need to submit this form each semester you intend to attend.
Name
NSHE ID
Signature
Date
* By signing above the student agrees to not be present on the University of Nevada, Reno campus for any reason during the indicated semester.
Semester requesting exemption for (i,.e. Fall 2015):
Fall 20____ Spring 20____ Summer 20____
Please indicate the Distance Education (Online) class(es) you would like to enroll in:
List course number and section: i.e ENG 101 5501
1.
2.
3.
4.
5.
Important note: Any enrollment request for a non-distance education (online) class will be denied using this exemption.
For Office Use Only
Approved
Denied
Evaluator Date
Student Information:
Class/Enrollment Information:
