Immunization Waiver

Immunization Requirement Waiver

Louisiana Law (R.S. 17:170) requires each person entering any school within the state for the first time, shall present either:

Satisfactory evidence of immunization against vaccine-preventable diseases according to the schedule approved by the Office of Public Health, Louisiana Department of Health, or shall present evidence of an immunization program in progress; or
Sign a waiver indicating they have chosen not to be vaccinated. By completing this form you are submitting a waiver and you will not need to send us your immunization records.

Student Name*

First NameLast Name

Student Banner ID*

Student Date of Birth*

MonthDayYear

Student E-mail*

Waiver Option*

I choose to sign a Proof of Immunization Waiver.

By signing below, I acknowledge that I have read and understand the immunization requirements. If I choose not to submit my records, I understand 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 immunization. If I am not 18 years of age, my parent or legal guardian must sign below. I do further hereby, now and forever, free and release the Louisiana Community and Technical College System and its member institutions from any and all legal and financial responsibility as a result of this refusal.

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

YesNo

Student Signature (18 years of age or older*

Parent Full Name *

First NameLast Name

Parent Signature (students who are less than 18 years of age)*

Please verify that you are human*