mHUB Vaccine Exemption Form

Please complete this form to apply for an exemption from mHUB's vaccine mandate for all members.

NOTE: If you are seeking a medical exemption you will need to also complete this form with a qualified medical professional and attach it to this application.

First and Last Name
Email Address
Company Name
My request is based on the following:
- Medical: Medical exemptions to immunization are available to those who have medical contraindications, precautions or other medical conditions/disabilities for which a licensed healthcare provider certifies that the individual is unable to receive the vaccine. Medical contraindications for immunizations are determined by the most recent Adult Immunization Recommendations of the ACIP, Public Health Services, U.S. Department of Health and Human Services, which is contained in the Centers for Disease Control and Prevention publication, the Morbidity and Mortality Weekly Report. A contraindication is a condition in a recipient that increases the risk for a serious adverse reaction. A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity. Please have a licensed medical provider complete the Medical Certification for Vaccine Exemption form and submit a copy along with this form (form linked above).
- Religious: As a private institution, we reserve the right to fully evaluate all religious exemption requests. A religious exemption requires a signed written statement from the member describing the reason for the exemption and must include the following, as dictated by the State of Illinois: The reason for the exemption in your own words, a description of the religious principle that guides your objection and an indication of whether this religious belief constitutes an objection to all immunizations or only this vaccine; if it is not an objection to all immunizations you must explain the religious basis for not receiving this particular immunization.
I attest to the following:
- As an unvaccinated individual, I am aware that I may be prohibited from the facility in the case of a vaccine-preventable outbreak or exposure.
Attach the medical exemption form or religious exemption explanation, as outlined above. Maximum upload size 10MB.
By signing, I confirm that all of the above to be true.

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