Revised 11/13/2020
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 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) and
THECB Rule 21.610 et seq.) due to enrollment in only classes that are exclusively online (distance learning).
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 24
0
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2644
FAX: (833) 431-1243 OR ADA: (855) 604-0915
Email: Health@unthsc.edu
Enrollment (Check Term)
Fall
Summer
Spring
Daytime Phone #
Date of Birth
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
Online Schedule Verified
Accepted
Incomplete
Denied
Completed By:
