Request Form for Exemption Application

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This form is not a vaccine exemption application.

This form should be used by those who want to submit a vaccine exemption application OR renew a previously granted exemption. If your form submission reflects that you are eligible to apply, you will receive an email with instructions on how to complete and submit the exemption application for consideration by the applicable review committee.

Please direct any questions to vaccine@barnard.edu.

Email *

First Name *

Last Name *

Phone Number *

Campus Affiliation *

Faculty

Staff

Student

Other:

Type of exemption requested *

Medical exemption

Religious exemption

Exemption Renewal

Send me a copy of my responses.

Submit

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