IMMUNIZATION EXEMPTION REQUEST FORM
1.
RELIGIOUS EXEMPTION:
•
A written statement is required from the student explaining the conflict with religious beliefs
for a religious
exemption. A religious exemption is not the same as a philosophical, moral or conscientious exemption.
2.
MEDICAL EXEMPTION:
•
A statement from a qualified healthcare provider explaining the medical contraindication is required for a medical
exemption, including the time period for which the exemption is valid.
• Medical Exemptions are to be reviewed annually and students who no longer have a valid or documented
medical reason for the exemption will be required to receive and document the missing immunizations.
IMPORTANT NOTE: In the event of a contagious outbreak, any student who has been exempted from immunizations will
not be allowed to remain on campus until the outbreak is declared over.
IMPORTANT NOTE: Exemption requests are evaluated on a case-by-case basis and are not automatic.
Additional requirements may apply.
I am requesting an exemption from the immunization requirements:
MEDICAL REASON: Reason and time period must be explained by healthcare provider. Please explain:
Healthcare Provider Printed Name/NPI:____________________________________ Signature:_________________
Address:_________________________________________________ Phone: _________________Date: _________
RELIGIOUS REASON: Receipt of vaccination and immunization would conflict with student’s sincere religious beliefs.
Please explain
(Must be explained by student):
Student Signature: ______________________________________________________________ Date: _________
Last name First name DOB (month day year) ID (A number or RUID)
