Immunization Exemption Form
Student Name
Date of Birth
SHU ID#
Please upload this completed document to the Student Health Portal - https://myhealth.sacredheart.edu
The Sacred Heart University New Student Health Form must also be submitted along with this form
A religious exemption is intended for people who hold a sincere religious belief opposing vaccination to the extent that if the state forced
immunization, it would be an infringement on their constitutional right to exercise their religious beliefs. A medical exemption is allowed
when a person has a medical condition that prevents them from receiving an immunization.
Please check all immunizations to which you are requesting an exemption:
Measles Mumps Rubella Varicella
Meningitis
Other: ____________________________________
RELIGIOUS EXEMPTION
In order to receive a religious exemption, please provide a brief statement in the space below explaining your beliefs that prevent you
from receiving the required immunizations:
MEDICAL EXEMPTION
In order to receive a medical exemption, you must have a physical condition whereby receiving one or more of the required immunizations
would endanger life or health. Your healthcare provider must state a reason for requesting medical exemption in the space provided
below:
By signing this form, I
hereby attest that the above information is accurate and I understand that immunization exemption for either
medical or religious reasons subjects me to exclusion from campus in the event of an outbreak of a disease for which immunization is
required.
Student Signature
Date
Parent Signature (
REQUIRED IF STUDENT IS UNDER AGE 18 ONLY)
X
Date
Healthcare Provider S
ignature (REQUIRED FOR MEDICAL EXEMPTIONS ONLY)
X
Date
Healthcare Provider Printed Name
Healthcare Provider Phone Number
X
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