IMMUNIZATION WAIVER

This form may only be completed if you are 18 years of age or older. If you are under 18 years of age a parent or legal guardian signature is required on a printed version of this form. If you are under 18 years of age CLICK HERE to download the printable form.

Nicholls ID Number(Required)

Date of Birth(Required)

Name(Required)

First Middle Last

Nicholls Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Request for Exemption – Measles, Mumps, Rubella and Td/Tdap Vaccine(Required)

YES

Reason for Exemption—Measles, Mumps, Rubella and Td/Tdap Vaccine(Required)

Medical (Physician's statement required below)

Religious (Statement Required Below)

Philosophical (Statement Required Below)

Please state Religious or Philosophical reason here.(Required)

Upload Physician's Statement here:

JPEG of paperwork or PDF

Drop files here or

Max. file size: 10 MB.

Request for Exemption—Meningococcal Vaccine (Meningitis)(Required)

YES

Reason for Exemption—Meningococcal Vaccine (Meningitis)(Required)

Medical (Physician's statement required below)

Religious (Statement Required Below)

Philosophical (Statement Required Below)

Please state Religious or Philosophical reason here.(Required)

Upload Physician's Statement here:

JPEG of paperwork or PDF

Drop files here or

Max. file size: 10 MB.

By signing below, I understand that if I claim exemption for medical, religious, or philosophical reasons, I may be excluded from campus and from classes in the event of an outbreak of Measles, Mumps, Rubella or Meningitis until the outbreak is over or until I submit proof of immunizations. I understand that if I decline the required vaccinations, I continue to be at risk for serious disease. I can always receive the vaccine(s) at any time. I have read and understand the vaccine information from the Centers for Disease Control and Prevention and understand risks and responsibilities in exempting/waiving the required immunizations. Nicholls State University, its Board of Trustees, and all of their agents are released from any liability should I contract Measles, Mumps, Rubella or Meningitis while I am enrolled. If I am not 18 years of age, my parent or legal guardian must download, print and sign the form at this link, Click here to download form.

Signature

By signing your name above using your mouse, pad, or finger, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By signing above using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Nicholls State University. You are also confirming that you are the student authorized to enter into this Agreement.

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