SJECCD of Immunization Affidavit - Religious Beliefs Exemption

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SAN JOSE EVERGREEN COMMUNITY COLLEGE DISTRICT (SJECCD) RELIGIOUS BELIEFS EXEMPTION:

SJECCD will consider sincerely held religious beliefs exemptions to the COVID-19 vaccine requirement on a case-by-case basis.

Religious beliefs exemptions require a signed written statement from the student describing the reason for the exemption and must include the information below. Any student granted a religious exemption acccommodation may be required to submit to mandatory weekly COVID-19 testing.

First Name *

Last Name *

Student ID *

College Email *

Mobile Phone

Entering Term (i.e. Fall 2021) *

Primary Campus (EVC or SJCC) *

Please acknowledge statements below: *

I request exemption from the COVID-19 immunization requirement for school entry because these immunizations are in conflict with my religious beliefs. I understand that in a case of an outbreak that I may be temporarily excluded from school for my protection I hereby release the San Jose Evergreen Community College District (SJECCD), it Board of Trustees, officers, employees, faculty and agents for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind that I may suffer as a result of my waiving the SJECCD immunization requirement.

Please provide a signed written statement describing the reason for the exemption and it must include the following: *

An explanation of the reason for the exemption, including a description of the religious principles that guide your objection. 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 immunization you must explain the religious basis for not receiving this particular vaccine (i.e. COVID-19). If you are under 18 years of age, a statement that your parent/guardian is aware that you may be prohibited from attending classes in the case of a vaccine preventable outbreak or exposure.

Please submit your written statement for the exemption: *

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Are you 18 years of age and older? *

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If you agree to the conditions of this immunization affidavit, please sign below with Adobe Sign:

Please have your parent/guardian complete the following part and sign below with Adobe Sign:

Parent/Guardian First Name

Parent/Guardian Last Name

Immunization Affidavit - Religious Beliefs Exemption Request