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Summary: UNIVERSITY OF ILLINOIS AT URBANA CHAMPAIGN
PETITION FOR EXEMPTION FROM THE REQUIREMENT OF PUBLIC ACT 85-1315,
MANDATORY PROOF OF IMMUNIZATION TO VACCINE PREVENTABLE DISEASES
ON RELIGIOUS GROUNDS
The Student Statement Describing His/Her Objections to Immunization
Based Upon Bona Fide Religious Tenets or Practices
(To Be Completed By A Parent Or Guardian if the Student is Less Than 18 Years Of Age)
I affirm that the statements made above truly reflect my beliefs and practices. I understand that should an outbreak of
a vaccine preventable disease occur on campus or in the community, I may be required to curtail my normal activities
and may be asked to avoid contact with other people in the interest of public health. I further understand that should I
contract a vaccine preventable disease, I will hold the University harmless and will comply with any and all limitations
placed upon me by the University of Illinois or Public Health Officials. I understand that I will be treated no
differently than any other person who has not demonstrated immunity to vaccine preventable diseases.
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Signature Date Birthdate
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Name (Please Print) University Identification Number
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Campus Address
Submit the completed petition to the Office of the Dean of Students, 300 Fred H. Turner Student Services Building,
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