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CON Request for Waiver of Faculty Immunizations or CPR Requirements: Difference between revisions
CON Request for Waiver of Faculty Immunizations or CPR Requirements (view source)
Revision as of 09:46, October 3, 2013
, October 3, 2013no edit summary
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<p style="margin-bottom:150px;">I, ________________________________________________, request a waiver of requirements for the following immunization(s) and or CPR, and include a signed statement from my primary care provider if for medical reasons:</p> | <p style="margin-bottom:150px;">I, ________________________________________________, request a waiver of requirements for the following immunization(s) and or CPR, and include a signed statement from my primary care provider if for medical reasons:</p> | ||
<p style="margin-bottom:150px;">for the following reason(s):</p> | <p style="margin-bottom:150px;">for the following reason(s):</p> | ||
<table style="max-width:70em !important;" width="100%" cellspacing="0" cellpadding="0" border=" | <table style="max-width:70em !important;" width="100%" cellspacing="0" cellpadding="0" border="0"> | ||
<tr> | <tr> | ||
<td> | <td>_______________________________________________</td> | ||
<td width="75px"> </td> | <td width="75px"> </td> | ||
<td>_______________________________</td> | <td>_______________________________</td> | ||
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<tr><td colspan="3"> </td></tr> | <tr><td colspan="3"> </td></tr> | ||
<tr> | <tr> | ||
<td> | <td>_______________________________________________</td> | ||
<td width="75px"> </td> | <td width="75px"> </td> | ||
<td>_______________________________</td> | <td>_______________________________</td> | ||