Immigration Vaccine Waiver Form

1

Are you seeking a vaccine waiver for immigration purposes?* This field is required.

YESNO

2

Do you have a religious or moral belief system that prevent you from receiving any vaccine?* This field is required.

YESNO

3

Do you make any other decisions based on your religious or moral beliefs?* This field is required.

YESNO

4

Have you received any vaccines in adulthood?* This field is required.

YESNO

5

What is the approximate date your received the most recent vaccine?* This field is required.

Date

6

Do you currently have an attorney?* This field is required.

YESNO

7

Have you already filed for your adjustment of status?* This field is required.

YESNO

8

Have you gone to your medical exam for immigration?* This field is required.

YESNO

9

Did you get any vaccines at your medical exam?* This field is required.

YESNO

10

Did the civil surgeon note that you're filing for a religious or moral waiver on your medical exam?* This field is required.

YESNO

11

Please describe your immigration situation and any concerns you'd like us to know* This field is required.

0/0

12

What is your name?* This field is required.

First Name

Last Name

13

What is your email address?* This field is required.

example@example.com

14

Google Click ID

15

Please verify that you are human* This field is required.

16

What is your phone number?* This field is required.

Please enter a valid phone number.