Online Student Immunization Waiver

Students who apply for admission to the University of Montana Western must provide immunization records showing proof of two doses of the Measles, Mumps, and Rubella (MMR) vaccination to be considered for admission. Students who are taking only online courses can waive this requirement by completing this form.

First Name

Last Name

Student ID Number | 800# (If Known)

Date of Birth

Online only students who wish to waive the immunization record requirement need to declare to the Office of Admission that they intend to take only online courses from Montana Western and must understand that if they do take an on-campus course from any Montana University System institution that they will need to provide immunization records showing proof of two doses of the MMR. To verify this information, please check the statement below, sign this form and submit it back to the Office of Admission.

I agree that I will be an online only student during my time with the University of Montana Western and I understand that if I decide to attend an on-campus course on any Montana University System campus, I will need to provide my immunization record.

In place of your signature, please type your full legal name. By typing your name, you are agreeing to the terms of this form.