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Summer/Fall 2022
Religious COVID-19 Exemption Request Form- Students
Student name
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First Name
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Last Name
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Student I.D. number
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Phone Number
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Student Email
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Do you regard yourself as having a sincerely held religious belief, practice or observance that you believe should exempt you from the COVID-19 Vaccination Requirement?
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Yes
No
Decisions on Religious Exemption Requests will be decided on a case by case basis. Religious beliefs do not have to be theistic, but can be non-theistic, strongly held moral or ethical beliefs. However, mere personal preferences - - beliefs based on social, political or economic philosophies, or veganism, for example - - are not considered religious beliefs. Students who hold a sincerely held religious belief will be engaged in an interactive process and accommodated, absent an undue hardship to the College.
If your answered yes above, please identify/explain the nature of your sincerely held religious belief, practice, or observance that is the basis for your request for an exemption as a religious accommodation and how long you have held or maintained the referenced religious belief, practice or observance.
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If your answered Yes above, please briefly explain how your sincerely held religious belief, practice, or observance that conflicts with El Camino College's COVID-19 vaccination requirement also how it impacts other aspects of your life.
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Have you previously received a vaccination of any kind after the age of 18 (e.g. vaccination(s) for Influenza (the “flu”), Hepatitis A, Hepatitis B, Tetanus, Measles, Chicken Pox, Polio, Yellow Fever, Human Papillomavirus (HPV), Tuberculosis, Shingles, Typhoid, etc.)?
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Yes
No
Provide below or attach any additional information supporting your religious accommodation request, including, but not limited to: Articles from religious scholars that describe the nature of the religious belief(s), practice(s), or observance(s); Excerpts from religious or sacred texts explaining the religious belief(s), practice(s), or observance(s); or Written materials that describe the religious belief(s), practice(s), or observance(s) that prohibit vaccination.
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Provide below or attach any additional information supporting your religious accommodation request, including, but not limited to: Articles from religious scholars that describe the nature of the religious belief(s), practice(s), or observance(s); Excerpts from religious or sacred texts explaining the religious belief(s), practice(s), or observance(s); or Written materials that describe the religious belief(s), practice(s), or observance(s) that prohibit vaccination.
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Student Signature: I hereby certify that my answer(s) are given to the best of my ability and are truthful and understand that I may be subject to student conduct procedures in the event my answers are found to be false.
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Dean's Decision
Dean's Decision
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Approved
Denied
Need more Information
Reason for Decision
Does not appear to be Sincere
Has taken other Vaccines under current Religion
Other:
Other Value
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