Request for Exemption from Immunization
Dear Student:
Submission of proof of certain immunizations is required as a condition of attendance at Hudson
Valley Community College. Such immunizations include:
Measles, Mumps and Rubella: The State of New York Public Health Law 2165 requires the
submission of a certificate of immunizations against Measles, Mumps and Rubella.
COVID-19: Based on FDA approval of a vaccine, the State University of New York requires
proof of vaccination; the College requires the submission of the vaccination card as proof.
Exemptions to the above requirements may be requested based on either religious conviction or
health reasons. To complete the exemption process, the Health Services Request for
Exemption from Immunization Form must be signed, notarized and returned. In addition,
documentation must be provided as follows:
Religious Conviction: Requests must be accompanied by a letter from your pastor
attesting that the you hold genuine and sincere religious beliefs which are contrary to the
practices of immunization. In the absence of a pastor’s letter, you can provide High School
Immunization Records indicating a religious waiver.
Health Reasons: Requests must be accompanied by a letter from you doctor indicating
you are not able to receive the immunization(s) due to underlying health conditions.
By signing the Request for Exemption from Immunization Form, you are acknowledging
that you understand that in the event of an occurrence of communicable disease, you will not be
allowed on campus and that you are assuming any and all risks associated with this decision.
Thank you for your understanding and cooperation.
Sincerely,
Claudine Potvin-Giordano
Director of Health Services
Hudson Valley Community College
80 Vandenburgh Avenue
Troy NY, 12180
