Vaccine Exemption Form

South Arkansas College may grant an exemption for students to an educational or other school-related requirements when a student's sincerely held religious beliefs, medical reasoning and philosophical reasoning.

Religious beliefs include sincere and meaningful affiliations with a religious group and moral or ethical beliefs as to what is right and wrong, which are sincerely held with the strength of traditional religious views. A letter or statement from your religious leader, should be provided.
For Medical Reasoning, please provide documentation from your Healthcare Provider.
For philosophical reasoning, provide a personal statement on your beliefs and reasoned judgement regarding the vaccine.

South Arkansas College reserves the right to request additional information reasonably needed to evaluate your exemption request and further engage in the interactive process to determine any accommodations(s) for your exemption request.

SouthArk may consider several factors in assessing whether a request for an exemption is based on a sincerely held religious belief, medical reasoning and/or philosophical reasoning. But no one factor is determinative. An individual’s beliefs—or degree of adherence—may change over time, and therefore, a student’s newly adopted or inconsistently observed practices may nevertheless be based on a sincerely held religious belief. All requests for a religious exception will be evaluated on an individual basis.

Student Name*

First NameLast Name

Student SouthArk ID*

SouthArk Email*

vanwil0000@southark.edu

Phone Number*

Please enter a valid phone number.

List the program you have been accepted to that required vaccination:*

List the vaccine(s) or other requirement you are requesting an exemption for:*

Please identify if your exemption will be based on your religious belief, medical reasoning, and/or philosophical reasoning.*

Religious BeliefMedical ReasoningPhilosophical Reasoning

Please explain how complying with this requirement would substantially burden your religious beliefs, medical reasoning and/or philosophical reasoning.*

Please upload documentation.*

Your exemption will not be processed without uploading documentation and agreeing to the terms below.

I, the undersigned, agree with the following statement:*

I verify that the information I am submitting here is complete and accurate to the best of my knowledge and that any intentional misrepresentation contained in this request may result in disciplinary action. I understand that my request for an exemption may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the internship site and/or to me, or if it creates an undue hardship on South Arkansas College or the internship site I am assigned to. I understand that in some cases, failure to adhere or consistently use the approved exemption may result in termination of the internship assignment if this failure would place the student's or others' safety at risk.

Date

Signature

For Office Use Only

For Office Use Only. Reason for Denial, if applicable:

VACCINE EXEMPTION FORM