COVID-19 Vaccine Medical Exemption Request Form

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To request a medical exemption from the SUNY COVID-19 Vaccination requirement, please complete this form below and have a medical provider complete part II and upload it below.

First Name

Last Name

Date of Birth

Student ID

Please check each box below to acknowledge:

While my request is pending, I understand that I must comply with the campus’ COVID-19 related health and safety protocols (e.g., masks/face coverings, social distancing, regular surveillance testing) applicable to unvaccinated or partially vaccinated individuals as a condition of my physical presence in a SUNY Facility.

I certify that I have confirmed with my academic program that not receiving the COVID-19 Vaccination will not prevent the completion of my programmatic or curricular requirements.

If my request is granted, I understand that I will be required to comply with the campus’ COVID-19 related health and safety protocols (e.g., mask/face coverings, social distancing, regular surveillance testing) if accessing a SUNY Facility as a condition of my on-going physical presence. I am aware that should a COVID-19 outbreak occur at the campus that I may be excluded from all in-person classes and activities and that if I am enrolled in courses that require a physical presence on campus that I may not be able to complete my academic coursework remotely. I acknowledge that any refund I might be entitled to in the case of a COVID-19 outbreak would be subject to all existing SUNY policies.

I certify that my statement above, and all supporting documentation, are true and accurate, and that I hold a sincere and genuine religious belief that is contrary to the receipt of the COVID-19 vaccination.

I understand that all exemption decisions are final, there will be no further appeal, and I will include all necessary information for an informed determination be made.

Please note that the campus reserves the right to request additional documentation to support a request for a medical exemption.

Part II Medical Exemption Request (to be completed by medical provider)

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