Complete this form if you are a Montana Tech student who seeks a medical or religious exemption to a vaccine requirement.

IMPORTANT: Religious exemptions for diphtheria, pertussis (whooping cough), tetanus, polio, measles, mumps, and rubella (MMR), H. influenza type B, hepatitis B, and/or varicella MUST be processed through Enrollment Services. Students seeking exemptions for those vaccines must complete the Affidavit of Exemption on Religious Grounds form and get it notarized before submitting it to Enrollment Services. DO NOT USE THIS FORM FOR THOSE EXEMPTION REQUESTS.