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Request for Religious Exemption from 

COVID-19 Vaccine Form

JVS requires that all participants receive a COVID-19 vaccination. A religious exemption may be granted if ALL of the following apply: 
  • The individual holds sincere religious beliefs which are contrary to the practice of vaccination
  • The individual completes and signs this form 
  • The individual provides the required documentation from a religious leader to support the exemption request
Participants 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 FAQ page.  

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

Please enter your initials for each of the statements below and enter in today's date at the bottom: