Exemption From Immunization Requirements

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MISSOURI WESTERN STATE COLLEGE
Esry Student Health Center
4525 Downs Drive, Student Union 203
St. Joseph, Missouri 64507
Telephone (816) 271-4495
Fax (816) 271-4498
EXEMPTION FROM IMMUNIZATION REQUIREMENTS
STUDENT NAME (Last, First, Middle)
Date of Birth
Social Security Number
I request exemption from immunization requirements based on the following:
My religious/cultural beliefs prohibit immunizations. (Indicate rationale and attach statement from clergy or
other authority.)
I have a medical condition that precludes immunizations. (Indicate rationale and attach statement from
physician.)
SIGNATURE OF STUDENT
DATE SIGNED
SIGNATURE OF PARENT/GUARDIAN
DATE SIGNED

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