COVID-19 Vaccination Exemption Declaration

Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

*Must be 18 years old or older.

Nicholls Email Address(Required)

Nicholls ID Number(Required)

I am requesting an exemption from the COVID-19 vaccination(s) and I am aware of the risks.

Reason for COVID-19 vaccination exemption declaration:(Required)

Medical

Religious

Philosophical

Statement for reason chosen above.(Required)

If exemption reason is medical, a physician's statement or medical record is required. Please upload required documents below.(Required)

Drop files here or

Max. file size: 10 MB.

Student Signature(Required)

Student must be 18 years of age or older. If you are under 18 click here for the downloadable form.

For more information contact: Louisiana R.S. 17:170 – Schools of Higher Learning University Health Services ● P.O. Box 2054, Thibodaux, LA 70310 Phone: 985.493.2600 ● Fax: 985.493.2601 ● Email: healthservices@nicholls.edu

Nicholls State University

COVID-19 Vaccination Exemption Declaration

I am requesting an exemption from the COVID-19 vaccination(s) and I am aware of the risks.

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