COVID-19 Vaccination Religious Exemption Form

Fillable blank form:

COVID-19 Vaccination Religious Exemption Form : CLICK HERE


Employee’s Name (Please Print or Type):
Employee City Number or Social Security Number Employee’s Date of Birth


I request exemption from the COVID-19 vaccination due to my religious beliefs.

Please identify your sincerely held religious belief, practice, or observance that is the basis for your
request for an exemption from the COVID-19 vaccine requirement.









Please briefly explain how your sincerely held religious belief, practice, or observance conflicts with the
Department’s COVID-19 vaccine requirement.










Please indicate whether your sincerely held religious belief, practice, or observance is in conflict with all

vaccines and, if not, the basis for the objection to the COVID-19 vaccine.










Please provide any additional information that you think may be helpful in reviewing your religious
exemption request.





 

I, the above-named individual, verify that the information I am submitting in support of my request for a
religious exemption is complete and accurate to the best of my knowledge. I understand that any

misrepresentation contained in or in support of this request may result in disciplinary action.
I also understand that my request for an exemption may not be granted if it is not reasonable, if it poses

a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an

undue hardship to the Department and/or City.

Employee’s Signature Date
Employee’s Printed Name
Work Telephone Number Work E-mail Address

Sworn to or affirmed and subscribed in my presence by _____________________________
(Employee Name)

this _____ day of _____________, 20___.


_____________________________________
Notary Public








THIS EXEMPTION WILL EXPIRE ONE YEAR AFTER THE DATE SIGNED BY EMPLOYEE ABOVE.

THE DEPARTMENT RESERVES THE RIGHT TO REQUEST ADDITIONAL INFORMATION IF REASONABLY
NEEDED TO EVALUATE YOUR REQUEST FOR A RELIGIOUS EXEMPTION.



Please direct any questions concerning this form to your Department/Division Human Resources Office.
Rev. 9/202

Please fill in the first three blanks at the top of the form with your personal information.

Below are the answers to the questions asked on the Exemption form. The yellow is the question, and the white is the corresponding answer to each of the four questions.

Please identify your sincerely held religious belief, practice, or observance that is the basis for your request for an exemption from the COVID-19 vaccine requirement.

As a Born-Again Christian, I trust in the design of our immune system that God has made for my body, and that God has the best immunity to Covid 19 and all other diseases and illnesses that can come upon me. God is truly my provider and protector in all things.

Please briefly explain how your sincerely held religious belief, practice, or observance conflicts with the Department’s COVID-19 vaccine requirement.

Currently I am being asked to consent to receiving a vaccine that is not tested and confirmed to be superior to that natural immunity God has provided me with. Even if it was tested and confirmed to be safe and effective, I would still trust God with the immunity He has provided me with over any man-made immunity.

Please indicate whether your sincerely held religious belief, practice, or observance is in conflict with all vaccines and, if not, the basis for the objection to the COVID-19 vaccine.

Yes, I have had vaccines in the past prior to my conversion to Christianity, however since I have become more knowledgeable about the Bible, I have come to realize that I need to trust my God, for all things regarding my health and finances. Especially this Covid Vaccine that I am being asked to receive, it has used parts of aborted babies in their laboratory testing, this is a crime to abort children, then use their bodies to try to save others. This is murdering one to save another and this is very much against my Religious beliefs. "Thy shall not kill".

Please provide any additional information that you think may be helpful in reviewing your religious exemption request.

I am a good citizen and love my country “the United States of America”. But I need to be able to make my own decisions on my personal religious, financial, and medical needs, so I pray that I would be allowed to do exactly that, “to make my own decisions on my religious, financial and medical needs”.

Thank You and may God Bless America.

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Page two has a sworn statement and will require: Employee’s Signature, Date, Employee’s Printed Name, Work Telephone Number, Work E-mail Address, and a stamp from a Notary Republic

Sworn to or affirmed and subscribed in my presence by _____________________________ (Employee Name) this _____ day of _____________, 20___. _____________________________________ Notary Public.

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