Governors State Immunization Exemption Form
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1Academic Resource Center
1 University Parkway
University Park, IL 60484
708.534.4090
Fax: 708.235.3961
Immunization EXEMPTION Form
Name: _____________________________________________________________________________________________________
(last, first, middle)
Date of Birth (mm/dd/yyyy): _____________________________
GSU Student ID number: ____________________________
Phone number: ________________________________________
Date of request: ____________________________________
Reason for Request:
Exemption - Date of Birth: Born on or before January 1, 1957.
Exemption* - Exclusively attend classes at an off-site location.
Exemption* - Enrolled exclusively in an online degree program, or all online courses.
*Advisor’s Signature: ___________________________________________________________________
Date: _____________
Student Signature: _____________________________________________________________________
Date: _____________
Submit this form in person to Academic Resource Center, B1215 or fax/mail to:
Fax: 708.235.3961
Phone: 708.235.7154
Mail:
Governors State University
Immunization Compliance - ARC
1 University Parkway, B1215
University Park, IL 60484-0975
GSU Immunization history form is available at .
06/2015
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Parent category: Financial