Preadmission Requirement printable pdf download

Preadmission Requirement

Certifi cation of Religious, Philosophical or Moral Belief Exception

to the North Dakota State Board of Higher Education

I request to be exempted from the North Dakota State Board of Higher Education requirement to provide proof of

immunity againstmeasles, mumps and rubella (German measles) and/or meningococcal disease (meningitis) prior to

enrollment at any North Dakota statecollege or university. I hereby certify that my sincere and genuine religious

beliefs, philosophical or moral preclude my participation in an immunization program.

(Explain the basis, in detail, of your religious, philosophical or moral objections to immunization in the space below. You may

add extra pages if needed.Identify the length of time you have held this religious, philosophical or moral belief. Also identify

whether you are a member of any particular faith,denomination or church which forms the basis for your objection.)

I understand that requesting this exception does carry some risk. In the event that an outbreak of measles, mumps or

rubella and/or meningococcal disease is declared I will be required to stay away from campus until the outbreak is

resolved. The North

Dakota State Department of Health defines an outbreak as one case. The length of an outbreak could be from two to

six or more weeks depending on the severity of the outbreak.

I understand that by signing this form I am accepting the conditions of this exception and will comply with these

restrictions.

__________________________________________________________________________________________

Name (last name, first name, middle initial — please print)

________/________/__________

Date of Birth

__________________________________________________________________________________________

Student’s Signature

________/________/__________

Date of Signature

____________________________________________________________________________(

)______________________

Local Address and Telephone Number (please keep these current at all times – promptly report any changes to the Admissions and Record’s Office)

On this ___________ day of _______________________ , _________ , before me,

____________________________________________________ ,

the undersigned officer, personally appeared ____________________________________________ , subscribed to the

within instrument and acknowledged that he/she executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I here unto set my hand and official seal.

________________________________________________________________

Notary Public Signature

My commission expires ________/________/__________

(SEAL)

Preadmission Requirement