College/University Exemption Denials 
As part of our legislative advocacy efforts, Health Action MA is collecting student medical/religious exemption denial testimonies from colleges/universities in the Commonwealth. 

Whether you were denied an exemption while you were/are actively enrolled, or during the enrollment process to a college/university in the Commonwealth, please complete the form below. 

Disclaimer:  information submitted in this form will not be shared publicly or with any third parties. 

Thank you 

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Email *
First Name *
Last name *
Town *
Zip Code  *
Phone Number
Who is filling out this form *
Which type of exemption was denied *
Was your medical exemption written due to an adverse event to the COVID-19 vaccine/booster? *
After the exemption denial..... *
If other please detail
Please provide a brief description of your exemption denial 
Future Communications: Do you consent to future communications from Health Action MA regarding legislative action/updates for college/university exemption denials. *
I would like to testify (written and/or verbally) before the legislature regarding my exemption denial. Please note: this will be public record.  *
A copy of your responses will be emailed to the address you provided.
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