CERTIFICATE OF IMMUNIZATION WAIVER FOR COLLEGE STUDENTS
Colorado law requires this form be completed and provided to the school if you choose to be
exempt from the Measles, Mumps and Rubella vaccination requirements.
Name:____________________________________________________________________________
(Last, First)
Date of Birth:______________________________________
(mm/dd/yyyy)
Student ID (CWID):_________________________________
If you are living on campus, a separate waiver will need to be completed for the Meningitis
vaccine. This waiver is on the Meningitis Information Form.
**Medical and Religious exemptions must include documentation from the student’s physician or
religious leader. Please submit both the waiver and the documentation together.**
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO EXCLUSION
FROM COLLEGE AND QUARANTINE.
DO NOT SIGN BELOW UNLESS ONE OF THE FOLLOWING CONDITIONS APPLIES
**MEDICAL EXEMPTION**
THE PHYSICAL CONDITION OF THE ABOVE NAMED PERSON IS SUCH THAT IMMUNIZATION WOULD ENDANGER LIFE OR
HEALTH, OR IS MEDICALLY CONTRAINDICATED DUE TO OTHER MEDICAL CONDITIONS.
SIGNED
DATE
(Physician)
**RELIGIOUS EXEMPTION**
PARENT OR GUARDIAN OF THE ABOVE NAMED PERSON OR THE PERSON HIMSELF/HERSELF ADHERES TO A
RELIGIOUS BELIEF OPPOSED TO IMMUNIZATIONS.
SIGNED
DATE
(Parent/Guardian or Emancipated Student/Consenting Minor)
PERSONAL EXEMPTION
PARENT OR GUARDIAN OF THE ABOVE NAMED PERSON OR THE PERSON HIMSELF/HERSELF ADHERES TO A
PERSONAL BELIEF OPPOSED TO IMMUNIZATIONS.
SIGNED
DATE
(Parent/Guardian or Emancipated Student/Consenting Minor)