Revised 04/19/2019
Petition to Waive Bacterial Meningitis Vaccination Requirement for
Enrollment in Exclusively Online Courses
This form may be used by new students, returning students or continuing students, under the age of 30, not enrolled for the
prior fall or spring term to request exemption from the bacterial meningitis vaccination requirement (Texas Education Code §
51.919/51.9192(b) ) due to enrollment in only classes that are exclusively online (distance learning).
Students must submit this form for each term in which the exemption is requested.
The completed form may be delivered in person, mailed, faxed or emailed to the UNTHSC Registrar's Office.
Return this completed form to:
UNT Health Science Center
Office of the Registrar, SSC 244
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2644
FAX: (817) 735-0448 OR Email: Health@unthsc.edu
STUDENT INFORMATION
UNTHSC Student ID #
Enrollment (Check Term)
Fall
Summer
Spring
Year
Last Name
First Name
Middle Initial
Mailing Address
Apartment #
Daytime Phone #
City
State
Zip Code
Date of Birth
Month Day Year
Age
Email Address
INITIAL TO ACKNOWLEDGE YOU READ AND AGREE TO THIS POLICY
I certify that I will only enroll in courses taught exclusively online for the above term. I understand
that if my status changes and I enroll in any course that is not exclusively online, I must immediately
submit the appropriate proof of bacterial meningitis vaccination to the UNTHSC Registrar's Office.
I understand that failure to do so will result in cancellation of enrollment in my course or courses.
By signing this form I certify that the information provided above is true and accurate.
Student's Signature -
USE BLACK INK ONLY
Month
Day
Year
Office Use Only
Online Schedule Verified
Accepted
Incomplete
Denied
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