College/University Exemption Denials

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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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First Name *

Last name *

Town *

Zip Code *

Phone Number

Who is filling out this form *

I am the student who was denied an exemption

I am the parent/guardian of the student denied an exemption

Other:

Which type of exemption was denied *

Religious Exemption

Medical Exemption

Was your medical exemption written due to an adverse event to the COVID-19 vaccine/booster? *

Yes

After the exemption denial..... *

I appealed the denial with the college/university and lost

I appealed the denial with the college/university and won

I persued legal action and won

I persued legal action was unsuccessful

I enrolled in another college/university in Massachusetts

I enrolled in another college/university out-of-state

I received the required immunization/s

I did not pursue college/univeristy any further

I do not wish to answer

Other:

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. *

YES - I consent to receiving communications from Health Action MA for college/university exemption denials

NO - I do not consent to communications from Health Action MA 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. *

Yes

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