Request for Medical Exemption from COVID-19 Vaccine Form

JVS requires that all clients provide proof of COVID-19 vaccination. A medical exemption may be granted upon receipt of a completed Medical Exemption from COVID-19 Vaccine form.  
 
Individuals with an approved exemption may be required to comply with additional testing and other preventive requirements as specified in the exemption approval and may be updated by later notification and/or posting of requirements on the JVS website at JVS Client Resources.  

In the event of an outbreak during a JVS program, individuals with exemptions may be excluded from all in-person activities, in order to protect all members of the community, until the outbreak is declared to be over.  

While JVS will carefully review all requests for medical exemptions, approval is not guaranteed. JVS's Director of Client Services, or their designee, will carefully review each request and determine if the request should be granted. After your request has been reviewed and processed, you will be notified if an exemption has been granted or denied. Decisions are final and not subject to appeal. Individuals whose requests have been denied are permitted to reapply if new documentation and information should become available.  

Requesting an exemption does not equate to registration as an individual with a disability. If you require disability-related accommodations outside of this exemption. Please contact Client Services Manager, Laura Combs, at lcombs@jvs.org for more information.  

Medical exemption process: 

  ● Read the CDC COVID-19 Vaccine Information:  Key Things to Know About COVID-19 Vaccines

  ● Complete and sign this form  

  ● Submit signed documentation from your Licensed Health Care Provider regarding COVID vaccine exemption 

Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time. 
Statements

Please enter your initials for each of the statements below: 








Documentation

Client Confirmation