OFFICIAL MERCED COMMUNITY COLLEGE DISTRICT FORM
STUDENT HEALTH FEE EXEMPTION
STUDENT FEES/#2201/NOVEMBER 2017
I hereby request exemption from the payment of any fee for the use of the Student Health Center or other health
services. I am an adherent of the teachings of a religious sect, 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 accordance with Section 76355 (c) of the Education Code
Section (c) (1), 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 subdivision (a):
(1) Students who depend exclusively upon prayer for healing in accordance with the teachings of a bona fide
religious sect, denomination, or organization.
____________________________________________________
Name (Printed)
Student ID #: ___________________Term:________________
This form must be submitted to the Student Fees Office by the end of the first week of the term in order to decline this fee.
This form can be faxed to (209) 381-6566 or submitted at the Student Fees Office.
OFFICE USE ONLY
Term: ________________ Date Received: ________________ Staff Initials: ______________ Date Processed: ________________ Staff Initials: _________
____________________________________________
Signature
Date: _______________________________________
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