STUDENT COVID-19 IMMUNIZATION REQUIREMENT All Saint Martin’s students are required to receive the COVID-19 vaccine and report it to the university prior to arriving on campus.*

1. Student information: Name: First Name: Last name: Saint Martin’s ID: Date of birth: Address: Street: City: State/Country: Zip/Postal Code: Phone: Saint Martin’s email:

2. COVID-19 vaccine information: Dose #1 (vaccine type) Date: Dose #2 (only need if Pfizer or Moderna) Date:

3. Submit via Dropbox: To complete, upload (1) this form and (2) a scanned image or photo of your vaccine card (required) to: https://smu-dropbox.stmartin.edu/index.php/s/iwMJB2p3jH5XYNF

* Saint Martin’s University follows immunization requirement recommendations from the Center for Disease Control, the American College Health Association, the Washington State Department of Health, and the Thurston County Public Health and Social Services.

Exemption request process Saint Martin’s University permits medical or religious exemptions to COVID-19 vaccination. To request exemption, 1) fill out the fields below and 2) send a copy of this form to [email protected]. The Student Health Center will notify students by email if their request has been approved.

Exempted individuals will be subject to certain campus restrictions if there is an outbreak or if the student exhibits symptoms. Detailed information about campus restrictions will be sent to exempted individuals.

Name: First: Last: Saint Martin’s ID: Date of birth: Phone: Saint Martin’s email:

I am submitting the following exemption request to vaccination:

Medical – The CDC considers a history of the following conditions as reasons not to receive the COVID-19 vaccines. (Note: None of the COVID-19 vaccines contain eggs, gelatin, latex, or preservatives.)  Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine  Immediate allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a component of the vaccine Note: A letter from a licensed health care professional (MD/DO/PA/NP), on their office letterhead, must be sent as an along with this form to [email protected] . Letter must include provider’s phone number for confirmation.

Religious – Exemption requests for religious reasons may be submitted as well.

version 6/2/2021