Vermont's Immunization Rule applies to undergraduate college and university students, who must have the required vaccines before entry unless exempt for medical or religious reasons. This two-page form covers both: page one is the medical exemption a health care practitioner signs, and page two is the student's religious exemption. It goes to the student health center before the student attends.
A health care practitioner completes page one, checking each vaccine that is or may be detrimental, the reason and the likely end date, then signs; the student signs the religious exemption on page two.
Download the current version from the source each time; forms change without notice.
College Immunization Exemption Forms
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A health care practitioner prints their name and phone number, signs and dates page one after checking the specific vaccines that are or may be detrimental and giving the reason. The religious exemption on page two is signed by the student, who attests to reviewing Department of Health educational material.
On this form, meningococcal ACWY applies to first-year dormitory residents only. Other undergraduates are covered for hepatitis B, Tdap, varicella, measles, mumps and rubella, and any of those can be marked for a medical exemption.