COVID-19 VACCINATION EXEMPTION FORM
2022-2023 ACADEMIC YEAR
Students and Employees who wish to exempt themselves from receiving the required COVID-19 vaccination must complete this form.
Dr. Christopher Siuta, Assistant Vice President for Student Life-Counseling, Health & Wellness; 716-926-8930 | firstname.lastname@example.org
This vaccine exemption is not correlated with remote academic accommodations. Students need to apply separately for any academic accommodations.
- Religious Exemptions: Student/Employee stating his or her religious belief(s) which prohibit immunization.
- Medical Exemptions: Student/Employee has a medical condition preventing him or her from receiving the COVID-19 vaccine.
I agree that my decision NOT to be vaccinated is a personal decision. I understand that in the case of a COVID-19 outbreak, at the discretion of the Wellness Center/Inspired Health Group and under the guidance of the New York State Department of Health, I may be temporarily given remote accommodations for classes and/or given the instruction to quarantine at home. This action would be taken not only to protect my health, but to reduce the risk to the Hilbert College community of further spread of the illness through me. It may be necessary to discuss your vaccination status with individuals on campus, on a case by case basis.