Name R Number Planned Arrival Date Early Arrival Group (If Applicable) RA PA Fall Athlete International Student Other Please Specify Request Return unvaccinated with full intent to be vaccinated as soon as possible. Return Partially vaccinated with full intent to be vaccinated as soon as my next dose is scheduled. Return unvaccinated with intent file for medical or religious exemption. Return unvaccinated with no intent to be vaccinated or file for exemption. Other Please Specify