COVID-19 Vaccination Exemption Request

Complete this form to request an exemption from the COVID-19 vaccination requirement. Approved waivers remain in effect for the duration of your program. There is no need to submit additional requests.

  • If your request is approved, your waiver will be sent to the Grayson student email address that you provide on this form. Be sure to use your @vikings.grayson.edu address. Double check your email address before submitting your request.
  • Waivers are not sent to personal, work, or other schools' email addresses.
  • Contact the Accessibility Services Office at hodgej@grayson.edu if you do not see your waiver in your student email. Do not fill out a second request form.

Please provide your Viking email.

Program Name*

Exemption Types:

You can request an exemption from the COVID-19 vaccination due to the following two exemption types:


  1. Qualifying medical reason - When selecting this option, you will attach your documentation from your licensed practitioner confirming your recognized clinical contraindications to COVID-19 vaccines. The documentation contains all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for you to receive and the recognized clinical reasons for the contraindications; and a statement by your practitioner recommending that you be exempted from the facility's COVID-19 vaccination requirements based on the recognized clinical contraindications for you.
  2. Sincerely held religious beliefs.

Exemption Type*

Please choose one of the two exemption options below.

The file upload tool below is for qualifying medical reasons only. It is not needed for sincerely held religious beliefs.

Drag and drop files here or

Acknowledgement: By submitting this exemption request, you are acknowledging that the information above is true to the best of your knowledge.

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