Petition to Waive Bacterial Meningitis Vaccination
Requirement for Distance Education Enrollment ONLY
Purpose of form: This form may be used by any new student to Texas A&M Health Science Center in order to advise the university that he/she is exempt from the vaccination requirement under section Texas Education Code 51.9191/51.9192(b) and THECB Rule 21.610 et.seq. because he/she is only enrolled in online or other distance education courses. Please return this form to the TAMHSC Office of the Registrar or the Student Affairs Office in your school/college.
Student Last Name: ___________________________ Student First Name ____________________________
UIN: ________________________________________ Date of Birth: ___________/____________/________
month day year
Telephone Number: ____________________________ Preferred Email Address: _______________________
Current physical address: ____________________________________________________________________
City: ________________________________ State: ______ Zip Code:________ Country: ________________
First Semester at Texas A&M Health Science Center (Select one and indicate the appropriate year):
___Spring, Year:_____ , ____Summer, Year: _____ , ___ Fall, Year: _____ .
Level of Study: ____ Undergraduate ____ Graduate ____ Professional (MD, DDS, or Pharm.D)
Please initial and sign below:
_____ I certify that I will only enroll in distance education courses. I understand that if my status changes and I enroll in traditional, face-to-face courses, I have an obligation to submit the appropriate bacterial meningitis vaccination documentation.
By signing this form, I certify the information provided is true and accurate. I acknowledge receiving information from the university about the bacterial meningitis vaccination requirement.
Student Signature _____________________________ Date ______________/________/___________
month day year