Request for Religious Exemption from COVID-19 Vaccine Form

JVS requires that all clients receive a COVID-19 vaccination. A religious exemption may be granted if:

The individual holds sincere religious beliefs which are contrary to the practice of vaccination,
Completes this form,

AND

Provides the required documentation from a religious leader to support the exemption request.

Clients with an approved exemption may be required to comply with COVID-19 testing and other preventive requirements as specified in the exemption approval and as 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 holding exemptions may be excluded from in-person activities for their protection, until the outbreak is declared to be over.

JVS’s Client Services Director, or their designee, will carefully review all requests, though approval is not guaranteed. After your request has been reviewed and processed, you will be notified, if an exemption has been granted or denied. The decisions are final and not subject to appeal. Individuals are permitted to reapply if new documentation and information should become available.

In order to submit a request, please:

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

● Complete and sign this form

● Upload documentation from a religious leader to support the exemption request

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:

I request exemption from the COVID-19 immunization requirement due to my sincere religious beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from JVS with respect to the required vaccinations.

I understand that as I am not vaccinated, in order to protect my own health and the health of the community, I will comply with all assigned COVID-19 testing requirements and other preventive guidance.

I understand that in the event of an outbreak or threatened outbreak, I may be temporarily excluded from in-person activities.

I agree to comply with these restrictions and accept responsibility for communicating with my JVS program point person as appropriate to allow compliance with health and safety requirements for unvaccinated individuals.

Should I contract COVID-19, I will immediately notify JVS through completing the JVS wellness form and contacting my JVS program point person.

I understand and agree to comply with and abide by all JVS's COVID-19 policies and procedures. I understand that this exemption is only valid while JVS's COVID-19 vaccination policy stands and I may need to submit a new request for any subsequent changes, new medical contraindications, or on expiration of an approved exemption. I further understand that the approval is provisional based on the current vaccination policy and is subject to change based on JVS's requirements moving forward.

I authorize my religious leader to provide JVS with information about my religious exemption for the COVID-19 vaccination.

I certify that the information I have provided in connection with this request is accurate and complete as of the date of this submission. I understand this exemption may be revoked if any of the information I provided in support of this exemption is false.

Documentation

Client Request for Religious Exemption from COVID-19 Vaccine Form - Without signed documentation from a religious leader, your application will be considered incomplete. Incomplete submissions will not be reviewed. Please upload appropriate documentation below:

Client Confirmation

First Name:

Last Name:

Email:

Program:

By selecting yes and typing my name above, I understand and agree that I am submitting this document electronically and that it is the equivalent of having placed my handwritten signature on the submitted document.

YESNO

Contact Information