Student Request for Religious or Reasons of Conscience Exemption
from COVID-19 Vaccine Form
UANET: Email: Phone:
The University of Akron is committed to providing an inclusive and supportive environment for
all and recognizes true and genuine observance of faith as it pertains to the practice of
immunization. A religious or conscientious exemption may be granted if (i) the individual holds
sincere religious beliefs, practice, or observance that are contrary to the practice of vaccination
or holds a sincere moral or philosophical conviction, such as the conviction that health and
disease should not be controlled by vaccination, (ii) completes this form, and (iii) provides the
required documentation to support the exemption request.
If approved, the exemption will remain in effect for the duration of the current academic year.
Individuals with approved exemptions may request to recertify exemptions each year. Individuals
with an approved exemption may be required to comply with COVID-19 testing and other
preventive health and safety measures.
Your requests will be carefully reviewed, although approval is not guaranteed. After your request
has been reviewed and processed, you will be notified, in writing, if an exemption has been
granted or denied. The decisions are final and not subject to appeal. Individuals are permitted to
reapply if new documentation and information should become available.
In order to submit a request, please:
Read the CDC COVID-19 Vaccine Information CDC COVID-19 Vaccine Information;
Complete and sign this form;
Complete and sign the Personal Statement Form; and
Submit the completed documents.
Incomplete submissions will not be reviewed. Be sure all forms and documentation are
submitted at one time.
Initial next to each of the statements below:
I request exemption from the COVID-19 immunization requirement due to my
sincere religious beliefs or sincerely held reasons of conscience. I understand and
assume the risks of non-vaccination. I accept full responsibility for my health, and
the risk of serious illness and even death due to lack of vaccination and release
The University of Akron from any and all responsibility and liability.
Because I am not vaccinated, in order to protect my own health and the health
of the community, I will comply with all applicable COVID-19 testing
requirements and other preventive guidance issued by the University
I understand that in the event of exposure to an outbreak or threatened outbreak,
I may be temporarily excluded or reassigned from The University of Akron’s
facilities and activities (including but not limited to University owned Residence
I agree to comply with these restrictions and accept responsibility for
communicating with faculty and advisors as appropriate to allow compliance with
health and safety requirements for unvaccinated individuals.
I further understand that restrictions from University facilities, including but not
limited to classes and living spaces, does not entitle me to any reduction in, ore
refund of tuition, housing charges, or other fees.
Should I contract COVID-19, I will immediately report it to The University of Akron
and comply with all isolation and quarantine procedures from Summit County
Health officials and the University.
I acknowledge that I have read the CDC COVID-19 Vaccine Information.
I understand and agree to comply with and abide by all of The University of Akron
COVID-19 policies and procedures, unless granted an exemption therefrom by the
I understand that, if approved, this exception is only valid for the current
academic year, and I am required to resubmit a new request for any subsequent
academic year(s).
I certify that the information I have provided in connection with this request is
accurate and complete. I understand this exception may be revoked and I may be
subject to disciplinary action if any of the information I have provided in support
of this exemption is false.
Printed Name: Date:
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Religious or Reasons of Conscience Exemption from COVID-19 Vaccine
Personal Statement Form
UANET: Email: Phone:
In the space below, please provide a personal written and signed statement explaining your
religious belief or reason of conscience as it pertains to your objections to vaccination, the basis
for that belief and how the University’s vaccination requirement would violate that religious
belief or reason of conscience. Please attach additional documentation, if necessary
I certify that my statement above is true and accurate and that I hold a sincere religious belief or
sincere reason of conscience that is against the receipt of the COVID-19 vaccination.
Printed Name:
Signature and Seal of Notary:
Subscribed and sworn before me on the day of , 2021
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