2022 Covid-19 Vaccination Exemption Request

Antioch College requires all students to receive a COVID-19 vaccination. COVID-19 vaccines are effective at keeping you from getting COVID-19, especially severe illness and death. COVID-19 vaccines also reduce the risk of people spreading the virus that causes COVID-19.

Students may request an exemption to the vaccine requirement on two grounds:

Medical exemptions: Some people may be at risk for an adverse reaction because of an allergy to one of the vaccine components or a medical condition. This is referred to as a medical exemption.
Religious exemptions: Some people may decline vaccination because of a religious belief. This is referred to as a religious exemption.

Please use this form and provide supporting documentation where appropriate to request an exemption to the COVID-19 vaccine requirement.

Which type of exemption are you requesting?

Medical Exemption

Religious Exemption

Medical and Religious Exemption

Student Information

Email Address

Legal First Name

Preferred (If you'd like to be called a name other than your legal first name)

Legal Middle Name (if applicable)

Legal Last Name

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Medical Exemption

A medical exemption may be granted upon receipt of this completed form as well as supporting documents from a licensed healthcare provider, not related to the submitter, and whose specialty is appropriate to the associated condition that includes the following:

Medical exemptions expire when the medical condition(s) contraindicating COVID-19 vaccination changes in a manner which permits vaccination or upon graduation. The assigned expiration is at the sole determination of Antioch College.

Individuals with an approved exemption will be required to comply with additional 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 Antioch College website.

The College will review all requests, though approval is not guaranteed. After your request has been reviewed and processed, you will be notified, in writing, if an exemption has been granted. If the approved exemption contains an expiration, you will be expected to complete the requirement at that time. Should the condition continue, or a new vaccination contraindication occurs, or the current exemption expires, a new request with updated documentation is required. 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:

Read the CDC COVID-19 Vaccine Information
Upload documents from your Licensed Health Care Provider or have documentation sent to nurse@antiochcollege.edu.
Submit this form.

Provider Name

Medical Provider Specialty:

Provider License Number:

Name of Provider Company or Practice:

Provider Address:

Provider Email:

Provider Phone Number:

If applicable, please upload supporting materials from your health care provider. Otherwise, your health care provider should send materials to nurse@antiochcollege.edu

Or, type or copy-and-paste your document here:

Religious Exemption

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 information to support the exemption request. Antioch College 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.

Religious exemptions must be requested annually. If approved, the exemption will remain in effect for the duration of the current academic year. Individuals with approved exemptions may request to recertify exemptions each year. The assigned expiration is at the sole determination of Antioch College.

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 Antioch College website.

Please check each of the statements below:

I request exemption from the COVID-19 vaccination requirements 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 Antioch College 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 additional COVID-19 testing requirements and other preventive guidance.

Should I contract COVID-19, I will immediately report it to Antioch College (email to nurse@antiochcollege.edu) and comply with all isolation and quarantine procedures specified by the College.

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

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

I understand that, if approved, this exception is only valid for the current academic year, and I am required to resubmit a new request for any subsequent academic year(s).

I understand that in the event of an outbreak or threatened outbreak, I may be temporarily excluded from Antioch College facilities and approved activities (including but not limited to Antioch College-owned 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 Antioch College facilities, including but not limited to classes and living spaces, does not entitle me to any reduction in tuition, housing charges, or other Antioch College fees.

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 the college’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 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.

You may upload supporting materials from your religious leader or parent describing the faith-based prohibition to COVID-19 inoculation.

Or, type or copy-and-paste your document here:

Confirmation and Electronic Signature

By checking this box and typing my name below, I understand and agree that I am submitting this document electronically and that it is the legal equivalent of having placed my handwritten signature on the submitted document.

Please type your full legal name

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2022 Covid-19 Vaccination Exemption Request