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.

果冻APP ID Number(Required)

Date of Birth(Required)

Name(Required)

First Middle Last

果冻APP Email(Required)

Address(Required)

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

Louisiana Law(Required)

Please read the following information carefully: Louisiana Law (R.S. 17:170.1/Schools of Higher Learning) requires all students entering 果冻APP to be immunized for the following: Measles, Mumps, Rubella, Tetanus-Diphtheria, Meningococcal disease (Meningitis), and COVID-19. The following guidelines presented on the back of this form are for the purpose of implementing the requirements of Louisiana R.S. 17:170.1, and of meeting the established recommendations for control of vaccine-preventable diseases as recommended by the American Academy of Pediatrics (AAP); the Advisory Committee on Immunization Practices to the United States Public Health Service (ACIP); and the American College Health Association (ACHA). Student鈥檚 registration will not be complete until they meet these requirements.

REQUIREMENT:
Measles requirement: Two (2) doses of live vaccine given at any age, except that the vaccine must have been given on or after the first birthday, in 1968 or later, and without Immune Globulin. A second dose of measles vaccine must meet this same requirement, but should not have been given within 30 days of the first dose.
Mumps and Rubella requirement: All students must show proof of vaccination against mumps and rubella.
Tetanus-Diphtheria requirement: A booster dose of vaccine given within the past ten (10) years.
Meningitis Requirement: Two (2) doses of meningococcal conjugate vaccination separated by at least eight weeks.

I have read the above information:

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

YES

Reason for Exemption鈥擬easles, Mumps, Rubella and Td/Tdap Vaccine(Required)

Medical (Physician's statement required below)

Religious (Statement Required Below)

Philosophical (Statement Required Below)

I have read and understand the below statement. (check box)(Required)

I fully understand that if I claim exemption for medical or personal reasons, I may be excluded from campus and from classes in the event of an outbreak of measles, mumps, or rubella until the outbreak is over or until I submit proof of immunization. If I am not 18 years of age, I must download the printable pdf form and my parent or legal guardian must sign it.

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: 50 MB.

Request for Exemption鈥擬eningococcal Vaccine (Meningitis)(Required)

YES

Reason for Exemption鈥擬eningococcal Vaccine (Meningitis)(Required)

Medical (Physician's statement required below)

Religious (Statement Required Below)

Philosophical (Statement Required Below)

I have read and understand the below statement. (check box)(Required)

BE IT KNOWN that on this date I have been fully informed by reading the Centers for Disease Control and Prevention鈥檚 Meningococcal Vaccines鈥擶hat You Need to Know Vaccine Information Statement (Click here to read statement.) and understand that my health could be negatively affected, and my life possibly endangered by not receiving the vaccine.

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: 50 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. 果冻APP, 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 果冻APP. You are also confirming that you are the student authorized to enter into this Agreement.

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