Fill - Free fillable SUNY Adirondack Office of Records and Registration (Adirondack Community College) PDF form



Page1of2  Updated11/05/2021

SUNY Adirondack Office of Records and Registration

ADDRESS: 640 Bay Road, Queensbury, NY 12804-1445

CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu



REQUESTFORRELIGIOUSEXEMPTIONTOCOVID‐19IMMUNIZATIONFORM



StudentswhoholdgenuineandsincerereligiousbeliefsthatarecontrarytoCOVID‐19Vaccinationmaybeexemptafter

submittingapersonallywrittenstatement,inone’sownwordsbasedontherequirementsbelow.Torequestareligious

exemptionfromtheSUNYCOVID‐19Vaccina

tionrequirement,ple asecompletethisformandsubmitittotheOfficeof

RegistrationandRecords.Adecisionregardingyourrequestwillbereleasedthroughyourcampuswolfmailaccount.



STUDENTINFORMATION:



ASTNAME,FIRSTNAMEDOBSTUDENTIDNUMBER



STUDENTSTATEMENT:

Please respond to the questions below, if additional space  is needed, please attach additional pages. General

philosophicalormoralobjectionstovaccines,articles/othermediasourcesopposingvaccines,orcopiesofwritingdone

bysomeoneelsemaynotbeusedaspartofanyexemptionrequest.



1. Howreceivingthevaccinationconfl

ictswithyoursincerereligiousbelieforpracticeby:

a. Describingthenatureandtenets[thedoctrine,principleorposition]ofyourreligiousbelief



b. Describingthepractices,ritualsandobservancesofyourreligiousbelief



c. Sharingwhen,whereandhowyouhaveadheredorembracedthereligiousbeli

eforpractice



d. Providingna

mesofotherswhomayhaveobservedone’spastadherencetoyourreligiousbelieforpractice



2. How not receiving the vaccination will not otherwise prevent comple tion of your programmatic or curricular

requirementsoftheacademicprogram.



Page2of2  Updated10/29/2021

 

Pleasenotethatthecampusreservestherighttorequestadditionaldocumentationtosupportthisrequest.

Pleasecheckeachboxtoacknowledgeeachstatement:

☐Whilemyrequestispending,IunderstandthatImustcomplywiththecampus’COVID‐19relatedhealthandsafety

protocols (e.g., masks/face coverings, social distan

cing, regular surveillance testin

g) applicable to unvaccinated or

partiallyvaccinatedindividualsasaconditionofmyphysicalpresence inaSUNYFacility.



☐Ifmyrequestisgranted,IunderstandthatIwillberequiredtocomplywiththecampus’COVID‐19relatedhealthand

safetyprotocols(e.g.,mask/facecoverings,socialdistancing

,regularsurveillancetesting)ifaccessingaSUNYFacility as

aconditionofmyon‐goingphysicalpresence.IamawarethatshouldaCOVID‐19outbreakoccuratthecampusthatI

may be excludedfromall in‐person classes and activities and that if I am enrolled in courses that re

quire a physical

presenceoncampusthatImay notbe abletocompletemyacademiccoursework remotely.I acknowledge thatany

refundImightbeentitledtointhecaseofaCOVID‐19outbreakwouldbesubjecttoallexistingSUNYpolicies.



☐Icertifythatmystatementabove,andallsupportin

gdocumentation,aretrueandaccurate,andthatIholdasincere

andgenuinereligiousbeliefthatiscontrarytothereceiptoftheCOVID‐19vaccination.



TUDENTSIGNATURE*DATE

*ParentorLegalGuardianmustsignifthestudentisunder18yearsoldasoffirstdayofclasses.



Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

SUNY Adirondack Office of Records and Registration (Adirondack Community College)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank SUNY Adirondack Office of Records and Registration (Adirondack Community College) Form

Related forms

Fillable SUNY Adirondack Office of Records and Registration (Adirondack Community College)

Fill Online, Printable, Fillable, Blank SUNY Adirondack Office of Records and Registration (Adirondack Community College) Form

Related forms

First 20 documents completely FREE!