Cisco Bacterial Meningitis Vaccination Exemption Form printable pdf download

Cisco Bacterial Meningitis Vaccination Exemption Form

Bacterial Meningitis Vaccination Exemption Form

(FOR STUDENTS UNDER THE AGE OF 22 REQUESTING AN EXEMPTION)

Student Information

Student Name:__________________________________________________________________

SSN:__________________________________________________________________________

Home Address:_________________________________________________________________

_____________________________________________________________________________

Telephone:____________________________________________________________________

Email:________________________________________________________________________

Please read and place an “X” next to the exemption you are requesting, sign, date and submit

to the Admissions Office.

I am claiming a bacterial meningitis vaccine exemption due to health reasons. Attached

is a signed affidavit or certificate from a physician that states the vaccination would be injurious

to my health.

I am claiming a meningococcal vaccine exemption due to reasons of conscience. A

notarized affidavit from the Texas Higher Education Coordination Board is attached.

I am taking only online or distance learning courses during the _____________semester

at Cisco College and will not be on a Cisco College campus or facility during the semester. I

understand and acknowledge that I will be required to submit a vaccination record if at any

point during the semester I enroll in a class at Cisco College. I also understand that this

exemption is valid for only one term.

______________________________________________

__________________________

Student Signature

Date

Cisco Bacterial Meningitis Vaccination Exemption Form