VACCINE RELIGIOUS EXEMPTION FORM
New York state law allows a student to request a waiver from a vaccination which is normally required by law if that student, or the parent(s) or guardian(s) of students who are younger than 18 years old, hold genuine and sincere religious beliefs which are contrary to the practice of immunization.  Complete all of the following information if you wish to receive a religious waiver from the Measles, Mumps, Rubella (MMR) vaccine.

Note: This form must be completed and signed by the student requesting the waiver if they are 18 years old or older.  It must be completed by the parent/legal guardian if the student is younger than 18 years.  

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Email *
Student's First Name *
Student's Last Name *
Date of Birth *
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Type of vaccine you are requesting a Religious Exemption for
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I attest that I, or the student identified above, has a genuine and sincere religious belief which is contrary to the practice of receiving a MMR vaccine (type initials below). *
I acknowledge that I, or the student named above, as a person unvaccinated to MMR, may be required to comply with certain public health measures, as directed by New York State law, the New York State Department of Health, the SUNY Administration, or Binghamton University, to have in-person access to the Binghamton University campus.  It is the student's responsibility to be aware of, understand, and comply with these measures (type initials below). *
I consent to be notified of the determination of this request using the e-mail address listed above.  I understand that e-mail is not a confidential method of communicating protected health information  (type initials below). *
Student Signature (or parent/legal guardian if < 18 years old as well as relationship to the student) *
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please select today's date: *
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