All Vaccination Declination Form – Religious

Name(Required)
Date of Birth(Required)

Vaccines Declined(Required)
Please check each vaccine for which you are requesting a declination:

I acknowledge that I am aware of the following facts:

  • I understand that declining vaccination/testing may increase my risk of contracting or transmitting these diseases.
  • I understand that, in the event of an outbreak or exposure, I may be subject to additional infection control measures, such as reassignment, masking, or exclusion from the workplace, in accordance with public health and organizational policy.
Religious Exemption Attestation(Required)
Signature(Required)