Religious or Medical Exemption from COVID-19 Vaccine

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First Name

Last Name

Student ID (from home university)

College for Social Innovation’s (CFSI) policy requires that all students receive a COVID-19 vaccination to participate in the Semester in the City program (SITC). A religious exemption may be granted if (i) the individual holds sincere religious beliefs which are contrary to the practice of vaccination, (ii) completes this form, and (iii) provides the required documentation to support the exemption request. College for Social Innovation is committed to providing a safe, inclusive, and supportive experience for all and recognizes true and genuine observance of faith as it pertains to the practice of immunization.

A medical exemption may be granted upon receipt of a completed form (below) not more than 6 months old, signed and certified by a licensed health care provider, not related to the submitter, and whose specialty is appropriate to the associated condition. Medical exemptions expire when the medical condition(s) contraindicating COVID-19 vaccination changes in a manner which permits vaccination or upon moving out of CFSI housing, as determined by CFSI in reviewing the request. The assigned expiration is at the sole determination of CFSI.

Individuals 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 CFSI website. In the event of an outbreak on or near campus, individuals holding exemptions may be excluded from SITC facilities and activities, for their protection, until the outbreak is declared to be over.

In order to submit a request, please:

Read the CDC COVID-19 Vaccine Information
Complete and sign the following page of this form
(if religious exemption) Have your religious leader complete the Religious Organization Statement Form; instructions can be on found on page 2 of this form.
(if medical exemption) Have your Licensed Health Care Provider complete the provider section of this form;
Submit the completed documents via our secure file transfer

Please select the type of exemption you are requesting

Religious Exemption

Initial next to 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 CFSI 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 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 or reassigned from CFSI’s facilities and approved activities (including but not limited to CFSI housing). I agree to comply with these restrictions and accept responsibility for communicating with faculty and advisors as appropriate to allow compliance with health and safety requirements for unvaccinated individuals. I further understand that restrictions from CFSI facilities, including but not limited to classes and living spaces, does not entitle me to any reduction in tuition, housing charges, or other CFSI fees.

Should I contract COVID-19, I will immediately report it to CFSI and comply with all isolation and quarantine procedures specified by the college and remove/quarantine myself from the CFSI community if so advised.

I acknowledge that I have read the CDC COVID-19 Vaccine Information.

I understand and agree to comply with and abide by all CFSI COVID-19 policies and procedures.

I certify that the information I have provided in connection with this request is accurate and complete. I understand this exception may be revoked and I may be subject to CFSI’s disciplinary action if any of the information I provided in support of this exemption is false.

In the space below, please provide a personal written and signed statement detailing the religious basis for your vaccination objection, explaining why you are requesting this religious exemption, the religious principle(s) that guide your objections to vaccination, and the religious basis that prohibits the COVID-19 vaccination. Please attach additional documentation, if necessary.

Information for Religious Leader

Name of Religious Leader

Title of Religious Leader

Name of Religious Organization

Religious Organization Email:

Religious Organization Address

Address Line 1

Address Line 2

City

Country

State

Provinces

State/Province

Postal Code

Do you give CFSI permission to contact your religious leader to gather further information?

YesNo

If you prefer that we do not contact them please have them submit a note providing a written and signed statement supporting the basis of your faith/beliefs which are contrary to the practice of vaccination or use of the COVID-19 vaccination. You can upload a note here or submit via the secure file transfer.

Medical Exemption

Initial next to each of the statements below:

I request exemption from the COVID-19 vaccination requirements due to my current medical condition. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from CFSI to the required vaccination.

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 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 or reassigned from CFSI facilities and approved activities (including but not limited to CFSI housing). I agree to comply with these restrictions and accept responsibility for communicating with faculty and advisors as appropriate to allow compliance with health and safety requirements for unvaccinated individuals. I further understand that restrictions from CFSI facilities, including but not limited to classes and living spaces, does not entitle me to any reduction in tuition, housing charges, or other CFSI fees.

Should I contract COVID-19, I will immediately report it to CFSI and comply with all isolation and quarantine procedures specified by CFSI and remove myself from the College community if so advised.

I acknowledge that I have read the CDC COVID-19 Vaccine Information.

I understand that this exemption will expire when the medical condition(s) contraindicating vaccination changes in a manner which permits vaccination, as determined by CFSI in reviewing the request.

I understand and agree to comply with and abide by all CFSI COVID-19 policies and procedures.

I understand that this exemption is only valid while the CFSI 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 CFSI requirements moving forward.

I authorize my licensed health care provider to provide Teachers College with medical information about my medical 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 and I may be subject to CFSI’s disciplinary action if any of the information I provided in support of this exemption is false.

Please contact your medical provider and instruct them to complete a copy of our Provider COVID-19 Vaccination Exemption Form which can be downloaded here.

Contact Information