Fillable KERN COMMUNITY COLLEGE DISTRICT STUDENT RELIGIOUS EXEMPTION REQUEST (City of Oakland)

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KERN COMMUNITY COLLEGE DISTRICT STUDENT RELIGIOUS EXEMPTION REQUEST (City of Oakland)

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KERN COMMUNITY COLLEGE DISTRICT
STUDENT RELIGIOUS EXEMPTION REQUEST FORM
FOR COVID-19 VACCINATION
Th
e Kern Community College District affords equal educational and employment opportunity for all
employees and for all qualified students, applicants, and volunteers as to all terms of employment
and prohibits discrimination against students, employees, applicants, and volunteers based on
classifications protected by law, including, but not limited to, religion, creed, and religious belief,
practice, or observance. Accordingly, the District provides exemptions for employees, applicants,
students, and volunteers whose sincerely held religious belief, practice, or observance conflicts with
an educational or employment requirement, unless providing a reasonable exemption would result in
undue hardship on the conduct of the District’s operations.
To
promote a safe and healthful workplace for students and volunteers, and to promote the health and
safety of students, employees, and volunteers working and learning on the District’s campus and
facilities, and members of the community, the District requires that all students and employees receive
their first COVID-19 vaccination (Pfizer or Moderna) by September 7, 2021 AND receive their second
vaccination (Pfizer or Moderna) in time to be fully vaccinated by November 1, 2021, OR receive their
COVID-19 single vaccination (Johnson & Johnson) in time to be fully vaccinated by November 1, 2021 in
order to be physically present on District premises, participate in District activities for more than fifteen
minutes at a time, or be inside a District building or office. This means that you should have the second
dose of the Pfizer or Moderna vaccination, or the single does of Johnson & Johnson vaccination a
minimum of two weeks prior to November 1, 2021.
St
udents and volunteers may use this form to request a religious exemption if they have a sincerely held
religious belief, practice, or observance that conflicts with the District’s requirement that all students
receive a COVID-19 vaccination. The District will consider requests for exemptions for sincerely held
religious beliefs on an individual basis. Exemptions will not be approved based on a purely personal
preference to not take the COVID-19 vaccine.
Submission
Once the submitter has reviewed and signed this form, submit the completed form to the appropriate
College’s COVID-19 Response Teams:
Bakersfield College: covid19@bakersfieldcollege.edu
Cerro Coso Community College: covid19@cerrocoso.edu
Porterville College: covid19@portervillecollege.edu
Al
low for three to five business days for your exemptions to be reviewed and processed. A member of
the COVID-19 Response Teams will confirm exemption via email.
Testing Once Confirmed
If
your exemption is approved, the student is agreeing to submit to a COVID test typically twice a week
based on your access to district facilities. Testing options will be provided during confirmation.
Additionally, you will need to continue to complete the Daily Health Checker form within the KCCD
Campus Pass App or Campus Pass Web Form.
STUDENT QUESTIONNAIRE FOR RELIGIOUS EXEMPTION REQUEST FORM
Section A: General Information
Student’s Name:
Select One:
BC
PC
CCCC
Secti
on B: REQUESTED EXEMPTION
Please sha
re why you are prevented from being vaccinated or attach additional information:
The Distric
t will consider your preferred exemption and other possible exemption that would resolve the
conflict between your religious beliefs, practices, or observances and will select, approve, and implement
the exemption that it deems effective.
In some cases, the District will need to obtain documentation or other authority in support of your
exemption request. This may include documentation from your religious or spiritual leader. If requested,
can you provide documentation to support your sincerely held religious belief and need for an
exemption?
Yes No
My signat
ure below indicates that the information I have provided in this form accurately reflects my
sincerely held religious beliefs, practices, or observances and its conflict with the District’s requirement
that all students receive a COVID-19 vaccination. I also understand that in evaluating my request for an
exemption, the District may require me to provide additional supporting documentation and may not grant
my request if it creates an undue hardship on the conduct of the District’s operations. I understand that
the District is relying on the information in this request to manage the health and safety of the District’s
students, employees and community. If the District determines that I have submitted false information I
can be disciplined up to and including termination.
Student ID Number
Student Signature
Date
FOR DISTRICT USE ONLY
Approved
Dismisse
d
Date Reviewed
Reviewed By (Print Name)
Page 2 – KCCD Student Religious Exemption FormUpdated: September 10, 2021
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KERN COMMUNITY COLLEGE DISTRICT STUDENT RELIGIOUS EXEMPTION REQUEST (City of Oakland)

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Completed 25 October 2021

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