Military Vaccination Exemption Waiver Form
Use this form to request an exemption from required vaccinations and provide the information needed for review.
Applicant and Service Information
Full Name
*
First Name
Middle Name
Last Name
Branch of Service
*
Please Select
Army
Marine Corps
Navy
Air Force
Space Force
Coast Guard
Other
Rank/Grade
*
Please Select
E-1
E-2
E-3
E-4
E-5
E-6
E-7
E-8
E-9
W-1
W-2
W-3
W-4
W-5
O-1
O-2
O-3
O-4
O-5
O-6
O-7
O-8
O-9
O-10
Other
Unit or Command
*
Duty Status
*
Active Duty
Reserve
National Guard
In Training
Retired
Other
Military Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Vaccination Exemption Request Details
Vaccine(s) Requested for Exemption
*
Influenza
COVID-19
Hepatitis A
Hepatitis B
MMR (Measles, Mumps, Rubella)
Varicella (Chickenpox)
Tdap
Meningococcal
Other
Exemption Type
*
Medical
Religious
Personal Belief
Other Applicable Reason
Basis for Request
*
Requested Effective Date
-
Month
-
Day
Year
Date
Prior Vaccination History Relevant to This Request
Supporting Information and Acknowledgment
Supporting Documentation
Upload a File
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of
Applicant Signature
*
Submit Request
Submit Request
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