Admissions & Records Office
3000 Campus Hill Drive
Livermore, CA 94551
www.laspositascollege.edu
FD ; 7.27.2020
(1) This for
m
m
ust be filled
o
u
t
c
o
mpletely and submitted before the established deadline.
(2) Attach written documentation with proof of exemption.
• You will be notified of the status of your request via
your Zonemail email account in approximately 10 –
14
business days
• For more information, please visit: http://www.laspositascollege.edu/admissions/fees.php
Last Name, First Name (PRINT)
Student Signature: _______________________________________________________ Date: ___________________
ADMISSIONS & RECORDS OFFICE USE ONLY
□ SHFL
□ In-person
□ Student
notified
Processed by: ___________
Date: _________________
A & R Administrator or Designee Date
A mandatory Student Health Fee of $21 for Fall and Spring, and $18 for Summer will be assessed for all students each semester or
session. This fee is used to support health services for enrolled students. In accordance with State Assembly Bill 982 and Section
76355 of the State Education Code, exemptions are only granted for the following: Students who depend exclusively upon prayer for
healing in accordance with the teachings of a bona fide religious sect, denomination, or organization; and students who are attending
Las Positas College under an approved apprenticeship training program.
INSTRUCTIONS:
I depend exclusively upon prayer for healing
in accordance with the teachings of a bona fide religious sect,
d
en
omin
ation, or organiz
ation
.
I am
a
tten
ding Las Positas College under an approved apprenticeship training program.
REQUEST TO OPT-OUT OF STUDENT HEALTH FEE
Student Health Fee Fall 2020 Due Date for submission: February 7, 2021
(3) Email the form and written documentation to: lpc-admissions@laspositascollege.edu
(4) This form needs to be submitted every semester or term.
IMPORTANT NOTICE:
