Vaccine Waiver Form
Name
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Which immunization(s) this wavier/exemption applies to
MMR (Measles, Mumps and Rubella)
Hepatitis B
Meningococcal (For first-time enrollees living in on-campus housing)
Other
Reason below for this wavier/exemption
PERSONAL OBJECTION:I hereby certify that the above immunization(s) are in conflict with my moral and/or religious beliefs and Iam requesting an exemption to the immunization requirements.
MEDICAL CONTRAINDICATION: I hereby certify that the immunization(s) specified above are medially contraindicated for me.
Physician Name
First Name
Last Name
Please upload Physician's statement and any other relevant document.
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I, undersigned, agree with the following statements
I am acknowledging that I have received and reviewed information on the risks associated with meningococcal disease, measles, mumps, rubella, hepatitis B, or other specified above.
I voluntarily agree to release, discharge and hold harmless any your organization, officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my decision not to be immunized.
I CHOOSE NOT TO BE IMMUNIZED.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
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