https://scccd.studenthealthportal.com/ .
State Center Community College District
HEALTH SERVICES
Student Request for Medical Exemption from Vaccination Requirement
Student Last Name: _______________________________________ First Name: _________________________________
DOB: _____________________ Student ID# _____________________ Phone: _______________________________
I give permission for the medical provider listed below to inform the College Nurse/Health Services Coordinator
that I am a patient under their care. Permission to release this information expires 1 year from my signature date.
Student Signature: _______________________________________________________ Date: _______________
MEDICAL PROVIDER VERIFICATION FOR VACCINATION EXEMPTION
State Center Community College District (SCCCD) requires COVID-19 Vaccination for all individuals who enter
buildings on SCCCD campuses/properties. This requirement aligns with health and safety guidance from federal,
state, and local public health authorities. Your patient is in the process of requesting a medical exemption from
the SCCCD COVID-19 Vaccine Mandate. Your assistance is requested to support this request.
Please answer the following as they relate to your patient:
Does this patient have a medical condition, a disability, or other impairment that
affects their ability to receive a COVID-19 Vaccination?
NO, my patient’s condition does not affect their ability to receive COVID-19 Vaccination.
YES, my patient’s condition does not allow them to safely receive COVID-19 Vaccination.
If “YES” above, please specify if condition is:
Temporary: Patient can receive the vaccination on or after (specify date): _______________
Long Term: Patient is unable to receive vaccination anytime in the foreseeable future
EACH OF THE FOUR ITEMS BELOW MUST BE COMPLETED
1. Medical Provider Name (please print): _______________________________________________
2. Medical Provider License #: ________________________
3. Medical Provider Signature: ____________________________________ Date: ____________
4. OFFICE STAMP:
INSTRUCTIONS: For approval of this request, the student must return this completed form to their
campus Health Services Office or upload the form at: The
student will be notified when this request is approved. Please allow 3-4 days for district processing.
HS-323 Vaccination Exemption Form
