Required Immunization Exemption Form

Hiram College Required Immunization Exemption

Religious and Medical Exemption Form
Exemptions to the vaccine requirements will be considered for individuals with medical conditions that prevent them from being vaccinated and for individuals with sincerely held religious beliefs that prohibit them from being vaccinated, consistent with federal and Ohio law.

Exemption requests will be reviewed by medical and disability services staff at the Julia Church Health Center, and students will receive a confirmation that their request is in process within three business days.
I hereby object and request the school to wave the immunization requirement against the following:*

D.T.P.TdapPolioMMRMeaslesMumpsRubellaHepatitis BMeningococcalAll Vaccines
Student's Name*

First NameLast Name
Type of Exemption Requested*

Medical: a signed statement required from your medical provider stating the condition.Religious: a signed statement required from your religious leader
Upload signed statement*

Cancelof
I further understand that during the course of an outbreak of any of the aforementioned vaccine preventable diseases, that the student named here is subject to exclusion from campus for the duration of the outbreak.

This action is necessary not only to protect this student, but the remainder of the students and faculty of the school.
Student Signature*

Clear
Parent/Guardian Signature (required if students is under 18)

Clear
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Hiram College Required Immunization Exemption