Immunization Waiver Form for Online Students Only
Immunization Waiver Form for Online Students Only I understand there is a Massachusetts state law requiring university students to submit immunization documentation for protection against diseases. I agree while completing my studies through the Bay Path University online program, I will not be on campus at any time. I agree that I will not enter the university campus for any reason during my enrollment. Do to this agreement, I waive the need to submit immunization documentation by completing this form.
__________________________________________________ Name Printed
_____________________________________________ Date of Birth
__________________________________________________ Student ID Number __________________________________________________ Signature
_____________________________________________ Date
Please return completed form to: Bay Path University Health Services 588 Longmeadow Street Longmeadow, MA 01106 Email: [email protected] Fax: 413-565-1104 Phone: 413-565-1392
__________________________________________________ Name Printed
_____________________________________________ Date of Birth
__________________________________________________ Student ID Number __________________________________________________ Signature
_____________________________________________ Date
Please return completed form to: Bay Path University Health Services 588 Longmeadow Street Longmeadow, MA 01106 Email: [email protected] Fax: 413-565-1104 Phone: 413-565-1392
