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,  
  • 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.  

Please enter your initials for each of the statements below: 


Client Confirmation