Admissions & Records
21250 Stevens Creek Boulevard, Cupertino, CA 95014
APPLICATION FOR EXEMPTION FROM
STUDENT HEALTH CENTER FEE
IN COMMUNITY COLLEGES
I hereby request exemption from the payment of any fee for the use of the student health center or
other health services provided in accordance with Section 76355 of the Education Code of the State
of California.
I am an adherent of the teachings of a religious sec, denomination, or organization, and in accord
with its teachings depend exclusively upon prayer for healings. Therefore, I request exemption from
the payment of the fee for health supervision and services provided in Section 76355 of the
Education Code in accordance with Section 76355 (c), which reads as follows:
“(c) the governing board of a district maintaining a community college shall adopt rules and regulations that
exempt the following students from any fee required pursuant to subdivsion (a): (1) students who depend
exclusively upon prayer for healing in accordance with teachings of a bona fide religious sect, denomination,
or organization and (2) students who are attending a community college under an approved apprenticeship
training program.”
____________________
CWID (student's ID)
_________________________________________________________________ (_______) ____________________
Name
of Bona Fide Organization Phone
*Note: If applicant is 18 years of age or over, signature of
parent or guardian is not necessary.
Rev. 4/26/16
________________________________ ________________________ _____________
Parent or guardian's Name Signature * (see note below) Date
________________________________ ________________________ _____________
Student's Name Student's Signature Date
______________________________________________________________ __________________________________________________
Street
City, State and Zip code
Office use only.
Term: __________ processed
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