COVID-19 Vaccine Religous Exemption Request Form

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Students who hold genuine and sincere religious beliefs that are contrary to COVID-19 Vaccination may be exempt after submitting a written statement that explains (1) how receiving the COVID-19 Vaccination conflicts with the student’s sincere religious belief or practice, and (2) how not receiving the COVID-19 Vaccination will not otherwise prevent the student’s completion of their programmatic or curricular requirements of the academic program. General philosophical or moral objections to such vaccine shall not suffice as the basis for a religious exemption.

First Name

Last Name

Date of Birth

Student ID

Student Statement:
In the space below, please describe the following: (1) your sincerely held religious belief or practice that is the basis for your request for a religious accommodation; and, (2) how your sincerely held religious belief or practice conflicts with the SUNY COVID-19 Vaccination Requirement. If additional space is needed, please attach additional pages.

Student Statement

You may attach supporting materials if you so choose. Examples of supporting materials include, without limitation:

A letter from an authorized representative of the religious institution attended by the student and/or literature from the religious institution explaining the doctrine/beliefs that prohibit COVID-19 immunization.
Other writings or sources upon which the student relied in forming religious beliefs that prohibit immunization.

Please note that the campus reserves the right to request additional documentation to support a request for a religious exemption.

Additional Supporting Materials

Please check each box below to acknowledge:

While my request is pending, I understand that I must comply with the campus’ COVID-19 related health and safety protocols (e.g., masks/face coverings, social distancing, regular surveillance testing) applicable to unvaccinated or partially vaccinated individuals as a condition of my physical presence in a SUNY Facility.

I certify that I have confirmed with my academic program that not receiving the COVID-19 Vaccination will not prevent the completion of my programmatic or curricular requirements.

If my request is granted, I understand that I will be required to comply with the campus’ COVID-19 related health and safety protocols (e.g., mask/face coverings, social distancing, regular surveillance testing) if accessing a SUNY Facility as a condition of my on-going physical presence. I am aware that should a COVID-19 outbreak occur at the campus that I may be excluded from all in-person classes and activities and that if I am enrolled in courses that require a physical presence on campus that I may not be able to complete my academic coursework remotely. I acknowledge that any refund I might be entitled to in the case of a COVID-19 outbreak would be subject to all existing SUNY policies.

I certify that my statement above, and all supporting documentation, are true and accurate, and that I hold a sincere and genuine religious belief that is contrary to the receipt of the COVID-19 vaccination.

I understand that all exemption decisions are final, there will be no further appeal, and I will include all necessary information for an informed determination be made.

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