Immunization Waiver

Louisiana law (R.S. 17:170) requires each person entering any school within the state for the first time, including elementary and secondary schools, kindergartens, colleges, universities, proprietary schools, vocational schools, and licensed day care centers, at the time of registration or entry shall present satisfactory evidence of immunity to or immunization against vaccine-preventable diseases according to a schedule approved by the office of public health, Louisiana Department of Health, or shall present evidence of an immunization program in progress. The schedule shall include but not be limited to measles, mumps, rubella, diphtheria, tetanus, whooping cough, poliomyelitis, meningococcal disease, and hemophilus influenzae Type B invasive infections.

Waiver Option

Student Name

First NameLast Name

Student Email

example@example.com

Pursuant to Louisiana R.S. § 17:170: In the event of an outbreak of a vaccine-preventable disease at Goodwill Technical College, the administrators are empowered, upon the recommendation of the Louisiana Office of Public Health, to exclude from attendance unimmunized students until the appropriate disease incubation period has expired or the unimmunized person presents evidence of immunization.

By signing below, I acknowledge that:

I have read and understand the immunization requirements.
I may be excluded from campus and from classes in the event of an outbreak until the outbreak is over or until I submit proof of immunizations.
If I am not 18 years of age, my parent or legal guardian must sign below.

Student Date of Birth

Date

Are you (the student) at least 18 years of age?

Student's Signature

Parent or Guardian's Name

First NameLast Name

Parent or Guardian's Signature